NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service THE ECLECTIC PRACTICE IN DISEASES OF CHILDREN. B Y JOHN M^SCUDDER, M. D. It2°l<~<\a PROFESSOR OF THB PRINCIPLES AND PRACTICE OF MEDICINE IN THB ECLECTIC MEDICAL INSTITUTE OF CINCINNATI J AUTHOR OF "A TKEATISE ON THE DISEASES OF WOMEN," "THE ECLECTIC MATERIA MEDICA AND THERAPEUTICS," "THE ECLECTIC PRACTICE OF MEDICINE," " THE PRINCIPLES OF MED- * ICINE," "SPECIFIC MEDICATION," "SPECIFIC DIAG- NOSIS," " THE USE OF INHALATIONS," ETC. REVISED EDITION. CINCINNATI: JOHN M. SCUDDER, Publishes. 1888. W5 \tVt -fUm no. )tfWlr\. free the practice of medi- cine from everything harsh and revolting, and to substitute those gentle means and appliances which, while successful in counter- acting disease, entail no present or future suffering. The practice of medicine in the past has been a chapter of horrors, which the truer civilization e>f the present will not tol- erate. " We may endure the sufferings of disease, with some degree of equanimity, but we will not have those sufferings in- tensified by medicines." This is the feeling of the better class of people, and especially of parents with regard to their children. If the author has aided to establish a better system of med- icine, and the present work fulfills its mission of rendering the treatment of the diseases of childhood certain and pleasant, he will be well repaid for his labor. It has been the object to make the descriptions succinct anel explicit, stating what the author believes to be true, and avoid ing theories. Thus, while the entire l'st of diseases has been studied the work has been kept in that moderate compass that renders it of easy reference to the busy practitioner. viii PREFACE. With regard to the treatment recommeneleel, the author offers the vonc.'ier of an extended and successful practice. It varies greatly from the treatment of the standard works of the day, or the teachings of the schools, but upon it he proposes to risk such reputation as he may have made as a teacher or writer. But few quotations have been made, and in these cases due credit has been given. While acknowledging no special obli- gations to any writer, the author begs to make that general acknowledgment to all who, writing on medicine, have revealed the germs of new truths, or have been instrumental in freeing old ones from the chaff in which they were enveloped, that they might be seen and applied. In this revision the author has adcled the results of the last twelve years' experience. The first part, on infantile therapen- rapeutics, has been entirely re-written, and forms a good materia medica. In the third part, the treatment has been mostly re- written, and the reader will find here the most successful treat- ment of the day. It is small doses of pleasant remedies for direct effect, which we believe will be the practice of the future. Cincinnati, June 15th, 1881. TABLE OF CONTENTS. PART I. INFANTILE THERAPEUTICS. PAGE. Chapter I.—Action of Remedies in Childhood. . . .17 Differences between the Adult and Child. . . 17 On account of the Nervous System, . . 17 Circulatory System and Blood, 19 Digestive Apparatus, . 20 Excretory Apparatus, . 20 Direct Medication, .... .21 Chapter II.—Form in which Remedies should be administered, 22 Solutions Preferred, . . . . . .23 The Dose of Medicine, ..... 24 Classification of Medicines. . . . . .25 Remedies which Influence the Nervems System, . . 26 (Telseminum, Quinine, Bromide of Ammonium, Belladonna. Opium. Carbonate of Ammonium, Rhus. Phosphorus, Iodide of Ammonium. Bryonia. Cain: hor. Ferro cyanuret of Potassium, Lobelia. iErluM-. ^Enothera, Pulsatilla, Chloroform, Asafcetida. Nux vomica, Chloral. Remedies which Influence the Circulation. . . 41 Aconite, Rhus. Podophyllin, Veratrum. Lycopus, Hamamelis, Gelseminum. Lobelia, Cactus. Eupatoriuni. Digitalis, Apocynum Canabinum, Spiritus iEthoris Nitrosi. TABLE OF CONTENTS. Remedies which Influence the Temperature, Baths, Veratrum, Acids, Food, Rhus, Alkalies. Air, Gelseminum. Cod Oil, Exercise, Bryonia, Phosphorus, Aconite, Baptisia, Sulphur, Remedies which Influence the Respiratory Apparatus, PAGE . 49 62 Aconite, Veratrum, Bryonia, Ipecacuanha, Lobelia, Phytolacca, Stillingia, Lycopus, Drosera, Sanguinaria, Euphorbia, Phosphorus, Senega, Scillae, Sticta. Rumex, Grindelia, Nitric Acid. Eupatorium Perfoliatum, Remedies which Influence the Digestive Apparatus, 69 Emetics, Ipecacuanha. Nux vomica, Hydrastis. Chamoniilla. Malt, Oxide of Zine Chionanthus, Cathartics, Colocynth, Chelidonium, Dioscorea, Iris, Amygdalus, Hamamelis, Podophyllin, Apocynum, Leptandria, Sulphate of Manganese,Pepsin, Santonine, Aloes, Uvedalia, Remedies which Influence the Urinary Apparatus. . . 82 Mentha Viridis, Sweet Spirits of Nitre, Rhus aromatica, Gelseminum, Acetate of Potash, Curcubitacitrullus, Eupatorium pur. Santonine, Agrimonia, Hydrangea, Benzoate of Lithia, Belladonna. Apis, Local Applications to the Loins, Remedies which Influence the Skin, Baths, Diluents. Asclepias, Saffron, Belladonna. Eupatorium. Antizymotics, Acids, Baptisia, Phytolacca, Antiseptics, Thymol, Carbolic Acid, Permanganate of Potash, Antirheumatics, Macrotys, Sticta, Bryonia, Apocynum, Phytolacca, Acids, Sedatives, Stimulants, Inunctions, Nepeta, Serpentaria. Sulphurous Acid, Sulphate of Soda, Sulphate of Iron, Sulphurous Acid, . 87 Rhus, Apis, Senega, Sulphur, Arsenic. . 95 Hydrochloric Acid, Chlorate of Potash. 100 Chloride of Lime, Chloride of Lead, Liquor Sodae Chlorinate, Salicylic Acid, Alkalies. 102 TABLE OF CONTENTS. \ntiperiodics, . Quinia Sulph. Alstonia Constricta Arsenic, Cinchonidia, Uvedalia, Nitric Acid knti-erysipelatous, .... Veratrum, Tinct. Muriate of Iron , Rhus, Apis, Sulphite of Soda, Restoratives, Air, Iron, Cuprum, Light, Phosphorus, Silica, Exercise, Sulphur, Soda, Food, Cod-Liver Oil, Lime. Tonics, PA RT II. CARE AND MANAGEMENT OF INFANTS. Chapter III.—Washing the Child, . Clothing the Child, How often should the Child be Washed ? Attention to the Cord, Ulceration of the Umbilicus, Excoriation and Chaffing, . Does the Child need Medicine after Birth, Difficulties in Nursing the Child, . Food for the Child, Composition of Milk, Liebip's Food. . . . . A Wet-Nurse, .... Weaning the Child, Sleeping. ..... Regular Habits, .... Moral Government, PART III. DISEASES OF CHILDHOOD. Chapter IV.—General Symptoms of Disease, . Physioh)gical Marriage, .... Life Line. ..... Temperature, Pulse, Respiration, xii TABLE OF CONTENTS. Chapter V.—Febrile Diseases, Pathology of Fever, Febricula, .... Intermittent Fever, Masked Intermittent, Remittent Fever, Slow Infantile Remittent Fever, Congestive Fever, Continued Fever, Typhoid Fever, Spotted Fever, Epidemic Cerebro-Spin 1 Meningitis, Diphtheria, .... Eruptive Fevers, Variola—Small-Pox, Varioloid, ..... Variola Vaccina—Cow-Pox, Spurious Vaccination, Can Syphilis be transmitted by Vaccination? Preservation of Vaccine, . . . Rubeola—Measles, Malignant Rubeola, Scarlatina, .... Anginosa, Maligna, Pertussis, .... Parotitis, .... Dyscrasias, .... Infantile. Syphilis, Poisonous Bites and Stings, Chapter VI.—Diseases of the Respiratory Apparat Physical Diagnosis, .... Coryza, ..... Chronic Catarrh, .... "' Pharyngitis, Tonsillitis, ..... Croup, .... Mucous. .... " Pseudo Membranous, . " Spasmodic, TABLE OF CONTENTS. (Edema Glottidis, Bronchial Catarrh, Bronchitis, Asthenic, Acute, . . . Chronic, Pneumonia, ..... Phthisis Pulmonalis, Chapter VII.—Diseases of the Digestive Apparat Dentition and its Derangements, Lancing the Gums, Care of the Teeth, Second Dentition, .... Stomatitis Simplex, Aphthae, ..... Stomatitis Ulcerata, Gangrenous, Sore Throat, .... Cynanche Maligna, .... Chronic Sore Throat, Gastrodynia, ... Gastric Irritation, Gastritis, ..... Infantile Dyspepsia, Colic, Diarrhoea, .... Muco Enteritis, .... Cholera Infantum, Tabes Mesenterica, Dysentery, .... Constipation, Prolapsus Ani, Intestinal Worms, .... Diseases of the Liver, Congestion of the Liver, Strumous Enlargement of the Liver, . Jaundice, ....<, Peritonitis, . . . , Hernia, « XIV TABLE OF CONTENTS. Chapter VIII.—Diseases of the Urinary Apparat Acute Nephritis, Chronic Nephritis, Albuminuria, .... Diabetes, .... Ischuria, ..... Enuresis, .... Urinary Calculi, .... Imperforate Urethra, Phymosis, ..... Paraphymosis, Urethritis, ..... Hydrocele, .... Infantile Leucorrhoea, Onanism, .... Chapter IX.—Diseases of the Nervous System, Determination of Blood to the Brain, Congestion of the Brain, Phrenitis, . Acute Hydrocephalus, Chronic Hydrocephalus, Spinal Meningitis, Curvature of the Spine, Epilepsy, ..... Convulsions, ... Chorea, ..... Trismus Nascentium, Night Terrors, .... Paralysis, .... Chapter X.—Diseases of the Eyes, Ophthalmia Neonatorum, Diseases of the Appendages of the Eyes, Furuncle, .... Ptosis, ..... Trichiasis, .... Diseases of the Lachrymal Apparatus, Ophthalmi Tarsi, Catarrhal Conjunctivitis, . , Opacity of the Cornea, TABLE OF CONTENTS. Chapter XL—Diseases f life more, I would but state the case as it presents itself to those who have most thoroughly studied children. The child is helpless, wholly dependent upon the care of its mother, and grows INFANTILE THERATEL'TICS. 19 into conscious life in an atmosphere of love. It responds pleas- urably to care for its welfare, and suffers acutely from neglect. We frequently meet with parents who seem to have no mental balance; now they are the most loving, then they are harsh passionate, and wholly without reason. In sickness, and when occasion offers to give advice, the injury, both to the physical and mental welfare of the child should be pointed out, and the influ- ence of the physician thrown in favor of a systematic effort for self-government. In some diseases, rest to the nervous system is absolutely essen- tial to life; in all it is of much importance. We will, therefore, carefully guard our own association with the child, that it may not be a source of irritation, calling the attention of parents to it, and prescribing remedies with reference to it. The good old times of physic, when a child could be thrown upon his back, his nose held, and the nauseous dose forced down his throat, as we would drench a horse, have passed by, for parents have learned quite as soon as physicians that it is not necessary to a cure. The Circulatory System and Blood.—Derangement of the circulation forms a very important part of most diseases of children. Very slight and temporary diseases present often marked change of pulse, while in the more grave affections it forms the basis of both functional and structural lesions. But while the circulation is thus easily deranged by causes of disease, it is readily reached and easily amenable to remedies. Possibly there is no part of the practice of medicine that will give more satisfaction than the use of remedies for this purpose. The blood of the child seems less subject to zymotic influences than the adult. Typhoid and typhus fever are of very rare occurrence, and epidemic dysentery and like affections pass the little ones by. On the contrary, the susceptibility to the eruptive fevers is greatest in early life. Lesions in blood-making are common in childhood, especially those that form the basis of that protean disease, scrofula; true, the lesion may be primarily of the lymphatic system, (Principles of Medicine, p. 236), but it manifests itself in imperfect elabora- tion of the blood. DefieieMit blood-making, though not more common than in the adult, is less easily influenced by medicine. Possibly because the digestive processes can not be stimulated by the same active tonic medicines. 20 DISEASES OF CHILDREN. The Digestive Apparatus.—The digestive tract is very sus- ceptible to the action of irritants, which unfavorably influence or arrest the processes of digestion, giving rise to crude and im- perfect products, and deterioration of the blood; not only this, but the influence upon the sympathetic nervous system is very marked, and is sometimes extended to the cerebro-spinal centers. A very common as well as marked example of this is, convul- sions from irritation of the stomach or intestinal canal. I have seen the most severe and persistent convulsions produced by the administration of some of the vermifuges, and even from castor oil. There is a less marked influence upon the nervous system from irritation of the intestinal canal, though frequently not less inju- rious. I speak of that which manifests itself in the form of nervous irritability, restlessness, and sleeplessness, which, as we have already seen, are to be carefully avoided. As the vegetative functions are in a very active condition, the child suffers more from deprivation of food than the adult. It has always seemed to me that the most serious error in the treat- ment of diseases of children, was the use of such means as woulel impair the power of the stomach to digest food, and destroy the appetite. Making no provision for a supply of nutritive material, the waste of the body would be stimulated to excess, and the child's life rapidly exhausted; using a homely simile, "it was burning the candle at both ends." The Excretory Apparatus.—As there is less waste of tissue, the excretory organs are not so active as in the adult, neither do they possess the power of sustained activity under the influence of medicines. While it will be found quite as easy to temporarily increase excretion, it requires much care to sustain these processes. Over stimulation frequently leads to such exhaustion that excretion is almost wholly arrested, and the little patient dies, poisoned by its own excreta. I do not know of any one point in infantile therapeutics that is more essential than this, in the more grave diseases. Given a disease that will require one or two weeks for its progress, and we may see how essential it is that the daily waste of tissue should be promptly removed. And we can never afford to hazard the successful termination of such disease, for the uncertainty of aborting it by over stimulation of the excretory organs. INFANTILE therapeutics. 21 DIRECT MEDICATION. In the treatment of the diseases of childhood especially, I prefer direct or specific medication, as I do in the treatment of the adult; but I find more directness of action in the case of the chilel, possibly because it is more free from the effects of a false civilization. The old methods of indirect medication may be employed when nothing better is known, but in the majority of cases the follow- ing rule will be found to yield the greatest success: "''Never give a de>se of medicine unless you see clearly the indication for that particular medicine, and have a reasonable certainty that its action will be beneficial." Of course, this cuts off hap-hazard medica- tion, or treating the name of a disease, and if persistently followed, will lessen the amount of medicine administered several hundred per cent. We have not yet specifics feir every disease, possibly for no disease in its totality, but we have specifics for pathological con- ditions, and, properly employed in the order in which these pathoh)gical conditions take precedence, they offer a direct and very certain treatment for diseases. In the eniple>vment of remedies we find greater success from doing one thing at a time, and, as a general rule, from the use of single remedies or very simple combinations. If we properly appreciate the different parts of a disease, we will find that they hold the relation to one another of cause and effect; that there are some primarv, and others secemdary and dependent upon the first; ami in the use of remedies we give those first that meet the primarv lesion, and follow with such as reach the indications of cure in the order named. In the treatment of diseases of children, as elsewhere, there is the constant tendency to view the sum of pathological processes as a unit, and to meet this at once. Though a physician knows well, if he reflects, that recovery will occupy days, he gives remedies to accomplish it in hours. All the remedies that would seem to be indicated in the whole treatment are given the first and each succeeding day. The true method is, to make a thorough analysis of the disease, and separate it into its component parts; determining also the oreler of these. Then remedies are selected, not with reference to the name, but with their application to correct a clearly under- stood pathological change of function or structure. 22 DISEASES OF CHILDREN. As an example, I may take inflammmation of the lungs. On analysis we find it to consist of an accelerated circulation, increased temperature, arrested excretion, difficult respiration, and cough, and more or less excitation of the nervous system. In addition to this, there is impairment of the digestive functions, and a gradually increasing lesion of the blood, and the processes of waste and nutrition. Such analysis tells us what the disease really is, and points out a specific or direct treatment. The accelerated circulation is controlled by the use of veratrum, to which gelseminum is added if there is much nervous irritation. The action of these is aided by the general bath, hot foot-bath, and a mush-jacket to the chest, which also relieves the irritation of the respiratory organs. Following this, if necessary, gentle diaphoretics, diuretics, and laxatives are employed to stimulate secretion. If the inflammatory process does not yield, the use of inhalations of the vapor of water, or a specific, like small doses of ipecacuanha, completes the cure. In the meanwhile any gastro- intestinal irritation, or other lesion, passes away as the circulation becomes normal and secretion is established. Very many times it requires but the remedies that control the circulation, for with this the entire series of morbid phenomena gradually disappears. CHAPTER II. FORM IN WHICH REMEDIES SHOULD BE ADMINISTERED Sue cess in the treatment of diseases of children will depend much upon the form in which the remedies are administered The first object is to have the proper medicine; the second, is to intro- duce it into the circulation without exciting any morbid process. It matters little with what skill the disease is diagnosed, or the remedies selected, if they fail to gain entrance into the blood. I doubt not that any physician can call to mind cases which will verify this statement. FORM OF REMEDIES. 23 The form of a medicine, then, is very important, and deserves our careful consideration. The remedy should not be objectionable to the taste, if it is possible to avoid it; for the unpleasant taste excites disgust, followed by more or less nausea, and during this but little if any absorption takes place. If now such remedy is repeated every one, two, or three hours, the disgust and nausea may be rendered persistent, and the remedies fail to produce the desired effect, because they do not get into the circulation where they may act. Many remedies undergo decomposition if retained in the stomach any considerable time, and either lose or change their medical properties ; hence, another reason for proper attention to the form, as well as some other accessories to their proper administration. Next to having the. remedy in a pleasant form is, to have it in solution or readily soluble in the gastric fluids. To gain entrance into the blood it must be in perfect solution, and as time is an important element in treatment, it is well to see that the remedy has these desirable qualities given it before it is introduced into the stomach. I prefer tinctures or solutions, and usually administer them with water. A very gooel method is to prepare the remedy in a glass of water, so that the proper quantity will be contained in a teaspoonful. I find that the slight taste is not objectionable, and to the child it does not look like medicine. If the child is old enough to observe, I prepare it in his presence, showing the bottles, the steps of the process, and then have him taste it and have his opinion of the result. In this way I find no difficulty in competing with homoeopathy as to the pleasantness of medicine. The mixing of medicines in compounds, using some syrup as a vehicle, and attempting to disguise the taste with peppermint, cinnamon, or something worse, is too disgusting now for the well- trained adult, and I do not wonder that it is objectionable to the chilel. I am very free to confess, that rather than have my children dosed with nauseous medicines, however good might be the physician, I should take the infinitesimal nothing of the homoeopath, and trust to nature for a cure. Powders are generally more objectionable than mixtures, ne>t only on account of their taste, but the difficulty in swallowing them, and their unpleasant influence in the stomach. They are also frequently less soluble, and are absorbed with greater difficulty. Syrups are not so objectionable in taste, yet frequently the 24 DISEASES OF CHILDREN. sugar undergoes decomposition in the stomach, producing irrita- tion. They are, however, very uncertain in their composition, and hence should be dispensed with. Occasionally we may employ the more powerful medicines by the use of homoeopathic pellets. They are easily prepared, but the dose is minute anel not definite in quantity. I have used aconite, veratrum, gelseminum, strychnia, morphia, and others in this form. Occasionally we may administer a remedy endermically when it can not be given by mouth. I have thus used quinia in inter- mittents and remittents, morphia, atropia, aconite, and some others. I do not recommend it however with any but the first two, and the use of these will hereafter be described. THE DOSE OF MEDICINE. The dose of medicine should be as small as will give the desired result. The harsh and immediate action of medicine is not usually desirable, but rather that gentle influence which is in the direction of healthy action, and which may appropriately be termed physiological. It is now generally admitted that the doses of medicine have been much too large, and that much in- jury has been occasioned by this over medication ; but there is no necessity of going to the opposite extreme of homoeopathy. In this, as in other things, there is a happy mean, which when found gives the best results. The doses recommended in this work are the maximum. The minimum, though not infinitesimal, would generally be regarded as too small to produce an effect. The human body, however, is a very delicate mechanism, and its processes most easily influenced, and we may readily believe that .it may be acted upon by anything of positive quality and appre- ciable quantity. A considerable experience in the treatment of diseases of children, has convinced me that the various processes of life are influenced with more certainty, and with far less liability ot injury through the sympathetic system of nerves, and that a very gradual influence is far more desirable than a speedy one. Another very important point in infantile therapeutics is th;;t the medicinal influence be continued until the desired result i* obtained. In other words, that, as the ultimate object is te> be slowly obtained, and that by repetitions of the remedy, gradually CLASSIFICATION OF REMEDIES. 25 increasing its influence from dose to dose, the doses should be so frequently repeated as not to lose the influence of one before another is given. Medicine should never be left for the sick to be given in drops, especially with children, who would suffer most from deviation in this respect. Let the remedy be added to some vehicle'—water is the best—so that the dose will be a teaspoonful. I have had one patient poisoned from neglect of this rule, and others injured, hence I place much stress upon it. There is, however, another reason for such dilution which may have some bearing : and that is, the medicine is placed in a form that it can be more readily absorbed. CLASSIFICATION OF REMEDIES. The classification of remedies is a work of no little difficulty, if we are to study them according to their specific action, which is the only method that will advance the practice of medicine. In the treatment of diseases of children, at least, we will abandon the olel methods of large doses with their poisonous effects, and substitute the small dose of pleasant medicine, kindly in its in- fluence upon the body, and directly antagonistic to the processes of disease. The old practice never gave good success. It added additional pangs to the suffering, new wrongs to those existing, prolonging the duration of disease and increasing its mortality. A purely expectant practice has proven far more successful; good nursing with diet and rest has given much better success; the water-cure has yieleleel better results, and homoeopathy has proven an incal- culable blessing to the suffering little ones. Whilst we administer remedies for the most part according to specific indications—special symptoms pointing out the remedies —some are given for their well-known physiological action, and because they influence spee'ial parts in a well known way. A large number of our remedies may be classified according to their action upon special parts or functions, anel I can not but think that such grouping will be of advantage. We will, therefore, study our remedies as—1. Those which in- fluence the nervous system; 2. Those which influence the circu- lation; 3. Those which influence the temperatni'e'; 4. Those" which influence the respiratory apparatus; 5. Those which in- fluence the digestive apparatus; 6. Those which influence the 26 DISEASES OF CHILDREN. urinary apparatus and its secretion; 7. Those which influence the skin and its function ; 8. Those which oppose the malarial poison—antiperiodics; 9. Those which oppose the process of zymosis—anti-zymotics ; 10. Those which oppose the process of sepSis—anti-septics ; 11./Those which oppose rheumatism—anti- rheumatics; 12. Those which oppose the poison of erysipeloid— anti-erysipclatous; 13. Those which oppose the syphilitic poison— anti-syphilitic, and 14. Agents that promote the processes of nutrition and increase life. REMEDIES WHICH INFLUENCE THE NERVOUS SYSTEM. Gelseminum, Quinine, Bromide of Ammonium, Belladonna, Opium, Carbonate of Ammonia, Rhus, Phosphorus, Iodide of Ammonium, Bryonia, Camphor, Ferro-cyanuret of Potassium, Lobelia, iEther, (Enothera, Pulsatilla, Chloroform, Asafoetida Nux vomica, Chloral, As has been already remarked, " the nerve centers of the child are immature and more easily influenced for harm than in the adult." It might also be stated that the nervous system of the child suffers more from disease, and remedies influencing it assume a more important place in infantile than in adult thera- peutics. It would sometimes seem as if the old doctrine—" that all diseases have their origin in wrongs of innevration "—was more than truth; at least, our acting upon it would be more nearly right than he who is always "acting upon the bowels." The influence of the nervous system, even the brain, upon the processes of vegetative life, is much more marked than in the adult, and the relief of a wrong of innevration will many times occur, when remedies directed to the disease as classified, have no effect. Instances will continually come up in practice when single remedies like Rhus, Gelseminum, Belladonna, Bryonia etc., are sufficient for the cure of seemingly complex diseases. The evidences of disease here will soon become plain to the careful observer, as he studies the position of the bodv its move- ments and expression, the expression of the face, its color the expression of the eyes, color, dryness and moisture, dilation or contraction of pupil, temperature, and the frontal, orbital and facial expression of pain. We do not claim that this is to be learned in a day or a year, but it will be learned in a satisfactory degree by him who gives it his attention. CLASSIFICATION OF REMEDIES. If now, we take some common examples, we may see the truth of the above. For instance, here is a patient (a grave case of disease) who is restless, starts in sleep, cries out suddenly and shrilly ; we look at the face, which is contracted, especially about the eyes or base of the brain ; the eyes are bright, and evidently the little patient suffers pain, as shown by the contraction of the frontal and orbital muscles. We give Rhus in small doses, and all the unpleasant symptoms fade away. Here is another, suffering from fever or inflainniatiou, which shows a flushed face, bright eyes and contracted pupils, with increased heat; there is restlessness, sleeplessness, it may be threatened convulsions, and thinking eif the usual means, it is a bad case. We admisister Gelseminum with Aconite, and there is speedy and marked amendment. In still another, we find the patient dull, sleepy, comatose; the eyes dull, pupil dilated, anel it may be a dull or dusky coloration of skin. We give Belladonna and these unpleasant symptoms soon pass away, and the patient convalesces. In another, the twitching of the facial muscles, the sudden movement of the head, and the involuntary movement of the extremities indicate the tendency to convulsions; the face is pale, brow contracted, circulation feeble, and we administer bromide of ammonium with a certainty of removing the unpleasant symptoms. Gelseminum. Specfiic Indications.—The face is flushed, eyes bright, pupils contracted, temperature increased, nervous system excited, patient restless and wakeful. Dose.—R; Tinct. Gelseminum, gtt. v. to gtt. xx., water oiv.; a teaspoonful every hour. When the irritation is very great anel the patient is threatened with convulsions the dose can be increased. Homoeopathic Indications, (3d to 6th decimal).—Bad effects from fright and fear, fright causes diarrhoea; vertigo with loss of sio-ht, chilliness, accelerated pulse, double vision ; great heavi- ness of the eyelids; paralysis of the eyelids and other parts; pupils dilated ; dull expression of countenance ; difficult articula- tion anel deglutition ; neuralgia, sharp, shooting pains through the face eyes and head. Scarlet fever with great nervous excitement, tonsils swollen and very red, pulse rapid.—Ehrmann. We use a saturated tincture of the green root; all other prepa- rations are imperfect or wholly worthless for the purposes for which we employ it. The difficulty in describing this, as well 28 'DISEASES OF CHILDREN. as some other remedies, so that the practitioner can employ them with success is, the very great difference in the quality of the article, as sold by different druggists. Gelseminum exerts an influence on the circulation like vera- trum and aconite, but less marked, and not so certain, and it is not for this purpose that I employ it. It has a specific action upon the cerebro-spinal nerve centers, relieving irritation and determination of blood to these parts. This is a use that renders the Gelseininuni a remedy of great value in treating the diseases of childhood. The action is so certain and definite, that we prescribe the remedy with great satisfaction. Given, a case of fever or inflammation, in which the child is uneasy, irritable and restless, the face is flushed, the eyes bright, the pupils cemtracted, and head hot, Gelseminum removes in a few hours all the un- pleasant symptoms. It is also one of our most valued antispasmodics. Its use is in those cases in which the convulsions are due to irritation of the cerebro-spinal centers. In a case of acute disease, the chilel presenting those involuntary twitchings of the muscles which indicates the approach of convulsions, there being the flushed face, bright eyes, and irritability, Gelseminum wards off the ap- proaching spasms, and relieves the child of them when they have appeared. Gelseminum also has an important action on theurinarv organs, which it is well to notice here. Occasionally a case of dysuria will be met with, consequent upon irritation of the neck of the bladder or spasmodic stricture of the urethra. Gelseminum will overcome the obstruction and cause a flow of urine, in a majority of cases. Belladonna. Specific Indications.—The patient is dull drowsy, comatose, dull heavy headache, the face dull and expres- sionless, the eyes dull, pupils dilated or immobile, capillarv circu- lation sluggish, as marked by deep color of skin or redness that is effaced by pressure of the finger, which leaves a somewhat per- sistent white line. Passage of large quantities of limpid urine involuntary passages of urine. Dose.—P^ Tinct. Belladonna, gtt. v. to gtt. x., water Siy • a teaspoonful every one to three hours. Homeopathic Indications, (3d to 6th decimal).__Throbbino- headache, with congestion of blood to the head, vertigo pulsa^ CLASSIFICATION OF REMEDIES. 29 tion e>f the carotids, worse from motion, light and noise are intol- erable; furious delirium, illusions, hallucinations, with flushed face and redness of the eyes; wishes to strike, bite or shriek, pupils dilated, eyes brilliant and staring; smooth, shining redness of the skin, hot, burning and itching; sore throat, with sensa- tion of a lump on swallowing, and great dryness of the throat; involuntary discharges of feces and urine from paralysis of the sphincters; pains come on suddenly, and leave just as suddenly. —Ehrmann. Belladonna causes contraction of capillary blood-vessels, doubt- less by stimulation through the sympathetic nervous system. Hence it is the remedy for congestion. Stasis of blood, or con- gestion, occurs in dilated capillary blood-vessels; indeed this condition of the capillaries is the cause of congestion. This action of Belladonna was first observed by Brown-Sequard in some of his physiological investigations. While this influence is exerted upon the entire circulation, it is most marked upon the circulation of the nerve centers. Thus we regard Belladonna as specific to congestion of the brain and spinal cord, anel the dullness and coma which are symptomatic erf it. In this respect Belladonna is the opposite of Gelseminum, which removes irritation and lessens determination of blood, the condition being an active one. Rhus Toxicodendron. Specific Indications.—The patient is restless, starts suddenly in sleep, sudden sharp cry, contraction of muscles about eyes and at base of brain, sharp frontal pain, especially in left orbit, small pulse with sharp stroke, tongue shows small red papillae at the tip, erythematous flushing of sur- face, small vesiculse about mouth and sometimes upon the skin. Dose.—R) Tinct. Rhus, gtt. v., water 5iv.; a teaspoonful every hour. Homoeopathic Indiations, (3d to 6th decimal).—Great debility, feelinor of soreness and lameness of the muscles, especially when at rest. Rheumatic pains, drawing and tearing in the muscles and joints. Stiffness of the joints, relieved by continuous motion. Paralysis of the limbs. Bad effects from getting wet. Putrid taste in the mouth, metallic taste. Very restless sleep before midnight. Violent stretching and yawning. Diar- rhoea, stools watery or of bloody mucus, frothy or white. Invol- untary stools at night while asleep. Dysentery with nausea and 30 DISEASES OF CHILDREN. tenesmus. Involuntary discharge of urine. Typhoid fever, dull stupid expression of the face, muttering delirium. Tongue dry, red, smooth. Restlessness. Involuntary passage of stools and urine, great exhaustion. Erysipelas with intense itching and burning. Scarlet fever or small pox before the eruption itches a great deal, with restlessness. Pustulous eruptions.—Ehrmann. This has a very extended use in the treatment of diseases of children. Commencing with the cases in which cerebral disease is a prominent complication, or indeed the principal element of disease, we find that this remedy relieves the excitement, pro- motes normal innervation through the sympathetic, and thus restores the circulation, waste and nutrition of the brain. It not only releives the brain and spinal cord, but it exerts a marked influence upon the circulation of blood, upon the temperature, upon waste and secretion, and upon nutrition. It presents us one of the most marked examples of the truth of the therapeutic maxim, " where a remedy is specially indicated, it will favorably influence every function of life, and sometimes do every thing that needs be done to effect a cure." Thus a malarial fever having the pronounced indications for Rhus will be cured by it better than by Quinine. An inflamma- tion of the eyes, of the lungs, of the bowels, of the urinary appa- ratus, or of any part, yields readily to Rhus, when it is specially indicated. It is a remedy frequently demanded in erysipelas and erysipeloid diseases, in zymotic and typhoid fevers, and in many endemic and epidemic diseases of children. Its use in the eruptive fevers, and in diseases of the skin will be named hereafter. Bryonia. Specific Indications. Headache in right side, with flushed right cheek; pain in serous cavities, with tension of muscles, and moderate tenderness on pressure ; sharp, lancinating pain, with tension of tissues; hacking cough with pain; dry skin, sensitive ; hard pulse, with moderate fullness, sometimes corded ; rheumatic pain. Dose.—R; Tinct. Bryonia gtt. v. to gtt. x., water giv.; a tea- spoonful every hour. Homoeopathic Indications (3d to 6th decimal).—In rheumatism and other complaints, marked aggravation on the slightest motion feels best when quiet; typhoid fever, with dry mouth and lips tongue is dry, rough, and cracked, and of a dark brown color • CLASSIFICATION OF EEMEDIES. 31 delirium at night of the business of the day; patient wants to go home; urine dark with pinkish sediment; pneumonia and pleu- risy, with sharp stitching pains on motion or breathing deeply; cough worse in warm room.—Ehrmann. Bryonia will be found a prominent anti-rheumatic, and also a remeely for pain, especially when the pain is increased by pressure. Physiologically it has been found to exert a special influence upon serous membranes, and when our little patient complains of pain in the articulations, abdominal pain with tenderness, pleuritic pain, headache, with tenderness of the eyes and temporal regions, ten- sive pain in the ears, we think of this remedy. It is a prominent remedy in disease of the respiratory apparatus —the cough irritative, hacking or rasping, pleuritic pain, sore- ness as if the parts were bruised, or soreness and tenderness of larynx and supra-sternal notch. It does not matter whether the disease is pneumonia or bronchitis, the Bryonia acts well. I wish especially to call attention to the abdominal pain and tenderness in typho-malarial fever, and in some zymotic diseases, as calling for this remedy. It may also be associated with Ipecac or Euphorbia in cholera infantum, when there is abdominal ten- sion and tenderness, or swelling and pain of articulations. Bromide of Ammonium. Specific Indications.—Sudden move- ments of body or extremities, jerking of the tendons, twitching of the facial muscles, want of accommodatoin in the eyes, eyes turned upward; face unusually pale, and pulse small, though I should not be guided by this. Dose.—For a child one to two years of age, I would prescribe, 5j- to 5'j- to water Siv-; a teaspoonful sufficiently often to control the symptoms and give rest. I employ bromide of ammonium to relieve the irritation of the brain and spinal cord, which gives rise to convulsions. It may be used to prevent the occurrence of convulsions when threatened, or to prevent their recurrence when arrested by other means. Regarding the remedy as a stimulant to the nerve cen- ters, we would use it when there was evidence of an enfeebled circulation of blood to the brain. There are a few cases of whooping cough in which bromide of ammonium will be found curative. In these there is an epilepti- form movement of muscles of the extremities associated with 32 DISEASES OF CHILDREN. the cough, and even the convulsive movements of the chest may O 7 be distinct. When convulsive disease has assumed a chronic fe>rm, as in epilepsy, I regard the bromide of ammonium as one of our most certain remedies. Its influence in childhood is more marked than in the adult. And its curative action is of course greater at the commencement of the disease than when it has continued for several years. I have employed it in a large number of cases of epilepsy, with very good success, a permanent cure re- sulting in a fair proportion. Pulsatilla. Specific Indications.—The child is restless, weary, cries frequently, sobbing even in sleep, face pale and ex- pressionless, pulse small and feeble. Dose.—R; Tinct. Pulsatilla gtt. v., water Siv., a teaspoonful every three or four hours. Homoeopathic Indications, (3d to 6th decimal).—Mild, yield- ing disposition, with inclination to shed tears. Vertigo when stooping or lifting up the eyes. The pains of pulsatilla con- stantly change their position, flying from one part to another. Painful inflammation of the eyes, styes, lachrymation in the wind. Dryness, burning and itching of the eyes and lids, with inclina- tion to wipe something away. Fistula lachrymalis. Obscura- tions of the cornea. Otalgia, darting, tearing pains. Discharge of mucus or pus from the ear. Measles with le>ose, rattling cough, photophobia, thick and yellowish coryza.—Ehrmann. Lobelia. Specific Indications.—The pulse is full and oppressed, breathing difficult, rattling of mucus in chest, dull expressionless face. Dull eyes, somewhat swollen, threatened convulsions, rest- lessness with uneasiness of bowels. Dose.—The dose will vary from the usual gtt v. to Mater 5iv. a teaspoonful every hour, to that which will prove nauseant or emetic. To relieve restlessness and pain, and improve the circula- tion and respiration the old prescription—R; Tinct. Lobelia Sem. 5j , Com p. Spirits Lavender 5iij., Simple Syrup giss.—will be found very good. Homoeopathic Indications, (3d to 6th decimal).__Nausea and vomiting, with flow of saliva; sensation of a lump in the throat impeding swallowing; asthma with burning feelino-in the chest and tightness; urine deep red color.—Ehrmann. infantile therapeutics. 33 Many of our readers will recall the old treatment of convul- sions in which Lobelia played so important a part as an antispas- modic. Compound Tincture of Lobelia and Capsicum (King's antispasmodic) was advised in all cases, and physicians would often wonder why, when the little fellows were so thoroughly drenched with this nastiness, the convulsions would sometimes persist even to a fatal termination. It was the old error of prescribing for names instead of conditions. The Lobelia is a powerful antispasme)dic, the conditions being as above named— an oppressed circulation. It is a stimulant to the brain and spinal cord, to the respiratory system, and to the ganglionic nerves. If the condition of the nervous system in convulsions is such as to require a stimulant, then Lobelia is a remedy. To quiet irritation of the nerve centers and give rest, the remedy must be given in doses less than nauseant, and, as above remarked, it may be combined with an aromatic, or alternated with Aconite or Nux. It also relieves irritation of the stomach upon which the restlessness many times depends. Nux Vomica. The child is restless, draws up its legs, con- torts its body, screams violently, wakes suddenly from sleep with crying, face flushes—intestinal irritation, colic, increased nervous sensibility. The face is pallid, sallow, yellowness about mouth, tongue pallid, nausea and vomiting, child uncomfortable, restless, sleepless, pallid, expressionless face and tongue, food distresses it, urine free but high colored, colors the napkins. Dose.—R; Tinct. Nux gtt. j. to gtt. iij., water 5iy-J from one- fourth to one teaspoonful every half-hour or hour. Homoeopathic Indications, (3d to 6th decimal).—Irritable; inclined to find fault, disinclined to talk; wants to be let aleme; nausea and vomiting; constipation, large difficult stools; uneasy feeling as if the bowels ought to move; ineffectual efforts to pass the feces; painful hemorrhoids; loss of appetite; restless sleep, wakes at 3 A. M.; eructations and heart-burn ; violent hiccough ; colic of whisky and coffee drinkers; can not bear the clothing tight around the waist; incarcerated hernia; dysentery, stools small and frequent, with ineffectual urging; retention of urine; suitable to persons of sedentary habits.—Ehrmann. Nux undoubtedly relieves irritation of the brain and spinal cord, when the circulation to these centers is enfeebled. One 3 34 DISEASES OF CHILDREN. might think, from its kindly action upon the intestinal canal and associated viscera, that the relief depends wholly upon this, but I am satisfied that it is not so. When the face is pallid and the pulse feeble, I have seen it relieve the patient from threatened con- vulsions, give rest and good sleep. In infantile paralysis, imperfect movement, and want of de- velopment of the extremities, it is a remedy to be thought of if the circulation is feeble. When the respiratory movements are feeble, in malarial disease, I would suggest Nux. It is not so important in retention of urine as santonine, but it may occa- sionally be used with advantage. It is the tonic of childhood, or rather the stomachic; for it is kindly received by the stomach and is not as objectionable to the taste as the most of bitters, while it increases the appetite and the power to digest food. When there is great depression of the nervous system, without fever or inflammation, it may be used with advantage. As an aeljuvant to quinia in periodic disease, especially in intermittent fevers, strychnia will serve a good purpose, and in some old cases, where quinia has been used to excess, we may arrest the periodic disease by its use. Quinia Sulphas. Specific Indications.—There is distinct periodicity in the disease. When administered the pulse should be soft, the skin soft or inclined to moisture, the tongue moist and cleaning, and the nervous system moderately free from irritation. Dose.—The antiperiodic dose of quinine may be stated at one grain for each year, a grain being the dose for a child six months old. This proportion will continue up to the sixth, eighth or tenth year, when it will stop until after puberty. In many cases the antiperiodic influence of quinine may be obtained from a minute dose, or, as we frequently use it, from its application to the skin by inunction. Homoeopathic Indications, (3d to 6th decimal).—Great debility resulting from loss of fluids, as in diarrhoea, hemorrhage, etc. • ailments which have a marked periodicity; metorrhagia with paleness of the face and coldness of the skin ; pulse impercepti- ble; ringing in the ears; diarrhoea, painless and debilitatino, stools undigested, worse after eating or at night; intermittent fever, followed by profuse and debilitating perspiration ; sensi- tive to the least draft of air.—Erhmann. INFANTILE THERAPEUTICS. 35 Many wrongs of innervation will be found to have distinct periodicity, whether they take the form of pain, restlessness, sleeplessness or tendency to convulsive action. In malarial re- gions the practitioner is continually on the watch for this, and even an obscure periodicity is thought to demand quinine, and its right use is followed by most satisfactory results. Quinine has been regarded as a tonic and a nerve stimulant, but these actions are doubtful unless there is the specific indica- tion. The inunction of quinine is frequently followed by in- creased appetite and digestion, a restful nervous system and better excretion, and patients recover rapidly from cholera infan- tum, slow forms of inflammation and obscure diseases, but I think in each of these cases a careful examination would deter- mine the malarial influence and periodicity. Ergot. Specific Indications.—Dullness, stupor, dull eyes, expressionless face, pulse slow and oppressed, tendency to con- gestion, hemorrhages. Dose.—R) Tinct. Ergot gtt. v., water oiv.; a teaspoonful every hour to three hours. Homoeopathic Indications, (3d to 6th decimal).—Great anxiety, fear of death. Wild, staring look, distortion of the eyes, vision obscured. Sunken countenance, eyes sunken. Spasmodic dis- tortion of the mouth and lips. Female complaints, especially in thin individuals. Vomiting of bile, with great weakness. Dry gangrene, beginning in the toes. Very debilitating diarrhoea. Cholera.—Ehrmann. The influence of Ergot upon the system is very similar to Belladonna, and as there is no other place where it can be more properly described, we will place it here. I have employed it in cases where there was an oppressed condition of the nervous svstem, with a tendency to coma, a labored respiration, and full oppressed pulse. In those cases in which, with such symptoms, there are convulsions, it will be found particularly useful. I should prefer Belladonna in febrile diseases; Ergot is non-febrile. Iodide of Ammonium. Specific Indications.—Headache with dizziness, unsteadiness of walk, feeble or sluggish circulation. Z)osc.—Rs Iodide of Ammonium grs. x. to 5ss., water §iv.; a teaspoonful four times a day. The indications for this remedy are occasionally met with in 36 DISEASES OF CHILDREN. diseases of children. Sometimes the lesion of brain is purely functional, but at others it will be found strumous or syphilitic. In the latter cases, I employ this and the iodide of potassium, where the tongue is broad and pallid ; Donovan's solution when it is small and red. Camphor. Specific Indications.—Pallid, expressionless face, pain, sleeplessness, with tendency to exhaustive discharges. Dose.—R; Tinct. Camphor gtt. v., water Siv.; a teaspoonful frequently repeated. Homoeopathic Indications, (3d to 6th decimal).—Coldness of the skin, at the same time patient does not wish to be covered. Sud- den prostration with diarrhoea. Retention of urine, with con- stant pressure on the bladder and desire to urinate. Pulse small, weak, and slow.—Ehrmann. vEther. Specific Indications.—Pain, or convulsive action, the face being pallid and cool, and circulation feeble. It is a very good remedy for the relief of headache from an enfeebled circu- lation. Dose.—R^ iEther 5j-, simple syrup gj.; ten drops to 5ss. may be given with a little water. As an anaesthetic it may be em- ployed with a napkin in the usual way of administering chlo- roform. With the indications named it will sometimes promptly relieve pain, give rest and sleep. It will also control convulsions, though the dose for internal administration is usually greater than that named. It is also sedative at least to the extent of lessening the frequency of the circulation. It is now regarded as a safer anaesthetic than chloroform, and many physicians use it exclusively. Some employ it with an equal amount of chloroform, its action being quicker. It may be used by inhalation to relieve pain, arrest convulsive action, and prevent its recurrence, as well as for complete anesthesia when surgical operations are to be performed. A spray of aether is used to produce local anaesthesia, in minor operations, also as a refrige- rant in cases of inflammation. Chloroform. Specific Indications.— Pain. Convulsions. Gall stones. Surgical operations. We prefer chloroform as an anaesthetic because of its speedier action, its move agreeable effect on the patient, and the greater INFANTILE therapeutics. 37 ease of its administration. We have used it for thirty years, without having a fatal case, and think that with care it is one of the safest remedies. Who can say as much for any of the agents in common use. Say Opium, Aconite, Veratrum, Gelseminum. The first I will guarantee has killed thousands, where one has been lost by chloroform. Chloroform is administered as an anaesthetic by using a folded napkin or handkerchief, cupping it, and sprinkling the fluid in the cavity. This is held over the nose in such manner that the vapor may be inhaled with a sufficient quantity of air. Especial attention is given to the respiration, which, if free, assures us that the patient is in no danger. If it becomes slow, difficult, or ceases, the inhalation is suspended, the child is turned quickly, anel two or three smart blows on the chest or buttocks restores the respiratory function. We use chloroform by inhalation to relieve intense pain, and to arrest convulsions. Of course it is not often demanded for the first, and its use in the second case is frequently temporary— we control the convulsions for the time being, until the indicated remedy can be given, and has time to act. This is much better practice than to allow the convulsive action to continue whilst we are vainly striving to get a medicinal action through the stomach. One of the most powerful antispasmodics at our command is found in chloroform. In the majority of cases it will be found safe as well as certain, but there is a class in which I think its use dangerous. There are cases in which there is congestion of the brain, and especially an impairment of innervation through the sympathetic nervous system, and a sluggish general circula- tion, with tendency to congestion of all important organs. It is somewhat difficult to diagnose such a condition ; but the begin- ner will do well to reject the remedy when the breathing is labored, the pulse not much increased in frequency, when the eyes are congested and the lips present a continued dusky or pur- plish appearance. Chloroform has been administered in very large doses with safety, though I do not think they should be recommended. As much as a teaspoonful has been given at once to a child two years o£ age, and repeated. A half teaspoonful is quite fre- quently named as a dose. I think that ten drops will usualJv produce the effect desired, and order the vehicle in such propor- 38 DISEASES OF CHILDREN. tion as to give this quantity in a teaspoonful. Simple syrup. glycerine, or mucilage, are good vehicles for its administration. Chloral Hydrate. Specific Indications.—To relieve pain, promote sleep, arrest convulsions, and relieve the cough of ner- vous irritation. It is contra-indicated when the circulation is sluggish, when there is atendency to congestion, pallid bluish lips, pale leaden tongue, dull eyes, and enfeebled respiration. Dose.—The dose will vary from one-half to five grains, for a child two years of age, and it may be given with syrup and water, as—Ri Chloral grs. xx., simple syrup 5ss. water Siss.; dose a teaspoonful. The element of danger in the administration of Chloral must never be overlooked. Adults have died from a dose of but ten grains, whilst as much as three hundred grains have been taken with safety. If, however, the rule given above is observed, I think its use will be safe. It must be regarded as a temporary remedy only, anel when the present emergency is passed it must be suspended for permanent remedies. Opium. Specific Indications.—The pulse is small and open, waves short, the face pallid, eyes dull, pain, sleeplessness. Homoeopathic Indications, (3d to 6th decimal).—Mania; delir- ium tremens; frightful or pleasing visions, alternating with stupor; steady stertorous breathing, with half open eyes; bad effects of fright; congestion of blood to the brain, with strong pulsations; staring look, glassy immovable eyes; apoplexy with deep snoring breathing, mouth open ; paralysis without pain ; trembling and twitching of the limbs; constipation, stools in round, black, hard balls; all ailments accompanied by sopor.— Ehrmann. Opium is a remedy that should be employed with very great care in diseases of children, though it need not be discarded. There are some cases, in which a judicious use of opium will calm irritation of the nervous system when all other means have failed, and in which this influence is essential to the preservation of life. The danger from the use of opium is, that its influence on the brain be such as to impair its circulation and nutrition. It first stimulates the nerve tissue and increases the circulation to it • and, secondly, exhausts the nerve tissue and causes congestion. infantile therapeutics. 39 The safest use of opium is in small doses to obtain its stimulant action, the remedy to be frequently repeated to continue the in- fluence. Occasionally a case occurs in which the little patient is very much exhausted, and suffers pain from this cause, there being neither fever nor inflainniatiou. In such cases opium may be used with advantage. The only trouble in such cases as it might be used with benefit is, that it tends to arrest secretion, and if arrested we have again a return of blood poisoning. Occasionally opium is given in the form of some soothing syrup, cordial, or other preparation to quiet children, until we have a condition of chronic poisoning. The symptoms are very marked—general emaciation, languor, a withered, sallow coun- tenance, red and swollen eyelids, derangement of the digestive organs with loss of appetite, and constipation of the bowels, with white stools. For young children the safest preparation is the compound powder of ipecac and opium of our Dispensatory. I generally add five grains to an ounce of water, sweeten with sugar, and have it given in doses of half a teaspoonful frequently, until the patient is relieved. Ammonium Carb. Specific Indications.—The pulse is feeble, circulation to the surface imperfect, skin pallid or dusky, respira- tion difficuft, restless and sleepless. Homosopathic Indications, (3d to 6th decimal).—Suitable for weak and nervous persons of sedentary habits. Scarlet fever when the rash is only faintly developed, with drowsiness, stupor, dry mouth, right parotid gland swollen, burning in the throat. —Ehrmann. Ammonia is an excellent diffusible stimulant, and may be employed in any case in which this action is desirable. The ses- quicarbonate of ammonia is a good form, and may be given in doses of one-half to three grains, in sweeteneed water. It is espe- cially in the prostration from acute disease that it will be found serviceable. Phosphorus. Specific Indications.—In acute disease there is a low grade of inflammation, with feeble circulation, and cerebral anemia; urine contains mucus, sometimes pus,and is passed with difficulty. In chronic diseases', an enfeebled nutrition of the brain, imperfect retrograde metamorphosis and combustion, with cacoplastic or tubercular exudations. 40 DISEASES OF CHILDREN. Dose.—In acute diseases—R; Tinct. Phosphorus gtt. j. to gtt. v., water 5iv.; a teaspoonful every one to three hours. In chronic disease I prefer the hypophosphites : hypophosphite of lime gr. ss. to gr. j. three times a day ; e>r the compound syrup of the hypo- phosphites, one-fe>urth to one-half teaspoonful after meals. Homoeopathic Indications, (3d to 6th decimal).—Very weak, empty feeling in the abdomen; heat up the back; constipation, long, hard, and dry stools, which are expelled with difficulty ; sour eructations and sour vomiting; desire for cold food and drink, which is vomited as soon as it becomes warm in the stom- ach ; vomiting of blooel; watery diarrhoea, coming away in a gush, followed by a sense of weakness ; sharp, shooting pains in abdomen ; hoarseness, loss of voice, croup, bronchitis ; hard, tight, dry cough, which is very exhaustive, worse from lying on the back or left side; expectoration salty, bloody yellow, purulent or of sour taste; more expectoration in the morning; pneumonia, respiration oppressed, quick and anxious; circumscribed redness of the cheeks; phthisis pulmonalis, particularly in tall, slim per- sons; pulse rapid.—Ehrmann. Ferrocyanide of Potassium. Specific Indications.—In chronic disease there is marked irritability of the nervous system, with restlessness and broken sleep; the pulse and respiration have their frequency increased; mucous membranes are pallid and lax with increased secretion, bowels irregular and tumid. Dose.—Rs Ferrocyanide of Potassium 5j>, water §iv.; a half teaspoonful to a teaspoonful three or four times a day. This remedy may be used in catarrh, chronic pharyngitis, threatened tuberculosis, or intestinal diseases simulating tabes mesenterica. Though named in this class of diseases—imperfect nutrition with tendency to aplastic deposits—the remedy is in- dicated by the peculiar nervousness, with enfeebled circulation and nutrition of the brain. CEnothera. Specific Indications.—A sallow, dirty skin, tis- sues full and expressionless, dull face and eyes, large sallow tongue, feeble innervation with broken sleep and tendency to cry on the slightest annovance. Dose.— X^ Tinct. (Enothera gtt. x., water giv.; a teaspoonful every three or four hours. Asafoztida.—This is one of the oldest antispasmodics in use and is a very good remedy in some diseases of children. The infantile therapeutics. 41 objection to it is its offensive odor and taste, which render it diffi- cult of administration. Its action seems particularly beneficial when the spasmodic or convulsive action arises from an irritation of the stomach, or parts associated with it. It is a gentle stimu- lant to the gastro-intestinal mucous membrane, and relieves irri- tation of it. The tincture of asafcetida with simple syrup offers the best means of administration. The dose of the tincture will be from ten to twenty drops. REMEDIES WHICH INFLUENCE THE CIRCULATION. Aconite, Rhus, Podophyllin, Veratrum, Lycopus, Hamamelis, Gelseminum, Lobelia, Cactus, Eupatorium, Digitalis, Apocynum Canabinum, Spiritus iEtheris Nitrosi. Lesions of the circulation are met with in almost all forms of disease, and in many are a principal element, so that if the cir- culation is brought to a normal standard and kept there, the dis- ease passes away. Readers will recall the teaching that there is in a majority of cases a first element of disease (basic element), upon which the disease is based, and which if taken away, the other wrongs disappear of themselves. This is frequently the case with the circulation. Here is a fever or an inflammation with a pulse of 120 beats per minute, small, and upon this as a base, we have a temperature of 104°, arrested secretion, irritation of the nerve centers, and symptoms point to the development of a typhoid condition. Aconite is given in the usual small dose, and as the pulse comes down to the normal standard, the tem- perature comes down, secretion is established, the nervous irrita- tion and pain pass away, the appetite returns, and the patient convalesces. But one remedy has been used, yet everything necessary has been accomplished. The association between frequency of pulse and temperature will be recalled, for every ten beats of pulse an increase of one degree of heat. If the pulse increases in frequency the tempera- ture increases, as the pulse conies down the temperature comes down. With a high temperature every process of life is im- paired, the cause of disease is intensified, and molecular death is rapid. As the temperature comes back to a normal standard the various functions are better performed, nutrition commences, causes of disease are less active, and the body frees itself from devitalized material. 42 DISEASES OF CHILDREN. Increased frequency of pulse intensifies inflammatory action, and looks toward death of the part. In inflammation of the respiratory apparatus, increased frequency of pulse causes in- creased frequency of respiration, cough, determination of blood, pain and unrest. We control the inflammatory process as we control and obtain a normal circulation of blood. Aconite. Specific Indications.—The pulse is small and fre- quent. (The indication is short but explicit). The remedy in- fluences special parts, as the throat, the larynx, bronchial tubes and intestinal mucous membranes, the indication being irritation with determination of blood Dose.—R; Tinct. Aconite gtt. iij. to gtt. v., water §iv. ; a tea- spoonful every hour. Homoeopathic Indications, (3d to 6th decimal).—Chill, followed by hot, elry skin, quick, full pulse; great restlessness and thirst, fear and anxiety of mind, sudden sinking of strength; congestion to head, chest, and heart; anxious, labored breathing.—Ehrmann. The pulse is small and frequent; it seems plain enough and yet it is sufficient for all our purposes. If it is a fever the tempera- ture will be increased in proportion to the frequency of the pulse, and the remedy will then reduce the temperature as it brings the circulation down to the normal standard. If, however, it be the cold stage of a fever, or an Asiatic cholera, it will in- crease the warmth of the body as it gives a natural circulation. The frequent small pulse is the indication in inflammatory dis- ease when there is marked irritation and determination of blood, (an active condition), but the remedy serves an equally good purpose if the circulation of a part is enfeebled—the pulse beino- small and frequent. Looking at the action of remedies in the usual way, this seems very strange—a paradox—but there is much in nature that we have not unraveled. If we observe the action of Aconite in fever, we find that as the pulse diminishes in frequency it in- creases in freedom, and there is a better circulation. If we neite its action in cholera we observe that as the pulse loses its fre- quency it gains volume and freedom, and there is a better circu- lation of blood. If we note its action in active inflammation we notice that it lessens determination of blood, quiets the irritation checks the rapid circulation in the capillaries where it is too active, and increases the circulation where it is slno-a-ish Tf „„ INFANTILE THERAPEUTICS. 43 we think, it acts upon and through the ganglionic system of nerves, we can account for all of this by saying that it gives right innervation. I have been in the habit of saying that Aconite was a stimulant to the heart, arteries and capillaries, be- cause whilst it lessened the frequency it increased the power of the apparatus engaged in the circulation. In noting the special parts and tissues, influenced by Aconite, we may coininence with the tonsils, the fauces and pharynx, where its influence may depend somewhat upon its topical actieui when swallowed. It has a direct influence upon the larynx, and is one of our best remedies in acute laryngitis and croup; indeed I would very much rather trust my patients with Aconite alone, than with all the old materia medica. Its influence upon the mucous membrane of the bronchia, even to the air cells, is very marked. The topical action of Aconite upon the stomach relieves irrita- tion, and frequently puts this organ in condition to receive renieelies and food kindly. It acts directly in relieving irritation of the intestinal canal from stomach to rectum, and proves one of our most efficient remedies in diarrhoea and dysentery, as well as in acute diseases of the associate viscera. It will be noted that Aconite has a wide range of use, especially in diseases of children. It may be called, par excellence, the child's remeely, for the indication—small and frequent pulse—is a cennnion condition in the acute diseases of children. I can almost agree with a medical friend who remarked, that if he had only the choice between Aconite, and the remainder of the materia medica, in diseases of childhood, he would take the one remedy. Veratrum. Specific Indications.—The pulse is frequent and full, may be hard, but has the quality of strength. The circula- tion is active, the skin somewhat flushed. It is the remedy in inflammation when the circulation to the part, and in the part, is active, anel where near the surface, when the surface is flushed red (the cole>r e>f arterial blood). Dose.—R; Tinct. Veratrum viride, gtt. v. to gtt. x., water giv.; a teaspoonful every hour. Homoeopathic Indications, (3d to 6th decimal).—Great arterial activity. Convulsiems or mania. Meningitis, cold sweat on face, hands and feet. The skin looks shriveled. Opisthotonos. Chorea, twitchings and contortions of the body. Froth constantly 44 DISEASES OF CHILDREN. on the lips. Chewing during sleep. Difficulty in swallowing. Neuralgia.—Ehrmann. The use of Veratrum is clearly indicated above. It is the remedy for sthenia, when the heart and muscles have power, and the circulation is strong. It lessens the frequency of the pulse, gives a free and equal circulation, lessens the temperature, and thus promotes better innervation and a better perforniance of all functions. Thus in many cases it will do all that is necessary to cure a fever. Its action upon any part engaged in inflammation is of the same character, whether it betaken internally or topically applied. It checks determination of blood by relieving irritation, slows the blood in the capillaries when it is running too rapidly, and at the same time it gives strength to the enfeebled tissues. This action may be witnessed in cutaneous or subcutaneous inflammation, or in erysipelas when the part has the flush of arterial blood. It seems to make but little difference where the inflammation is located, as it influences the entire circulation. It is claimed by some that Veratrum is one of the best altera- tives in our Materia Medica, and it is true that in its influence upon the ganglionic nerves and the circulation, it puts the excre- tory apparatus in the best condition for its work, and favors ret- rograde metamorphosis. It does not depress the heart or the patient as has been taught. In medicinal doses it increases the strength, and favors normal functional activity, or it gives a better circulation of blood. Act- ing through the sympathetic system of nerves, it not only gives a slower and a better circulation of blood, but it influences every organ and part supplied by this system. It thus improves the condition of the stomach and intestinal canal, favors appetite digestion and blood-making, and improves secretion. Topically applied it relieves irritation, checks determination of blood, and arrests the inflammatory process. It has been used with the best results in this way, to control inflammatory action. It is employed as a local remedy in erysipelas when the inflam- matory action is active, the part having the color of arterial blewd. Gelseminum.—A study of Gelseminum has been given under the head of " Remedies which Influence the Nervous System " Its influence upon the circulation is very direct, when the fre- quent pulse is based upon an excited condition of the nervous INFANTILE therapeutics. 45 system. The flushed face, bright eyes, contracted pupils, with in- creaseel temperature, are the indications, but with this, it lessens the frequency of the pulse, lowers the temperature, controls the inflammatory process and favors secretion and excretion. The Gelseminum case (the remedy being used in our dose) has a vigorous circulation, the pulse being frequent and free, usually full, the capillary circulation also being free. Locally there are evidences of determination of blood. Eupatorium Perfoliatum. Specific Indications.—The pulse is full, free and strong, the surface flushed, temperature increased, tendency to perspiration, pain in the loins, fullness of chest with sense of oppression, sense of weight with pain in lumbar region, frequent desire to urinate, urine cloudy. Dose.—Hfy Tinct. Eupatorium gtt. x., water giv.; a teaspoonful every hour. Homoeopathic Indications, (3d to 6th decimal).—Intermittent fever, paroxysm generally commences in the morning, thirst a long time before the chill, after the chill vomiting of bile, pain in the bones, as if broken, before the chill. The fever goes off by perspi- ration and sleep. During the apyrexia loose cough.—Ehrmann. Our readers will recollect the old use of "boneset" following an emetic " to keep the fever down," and produce diaphoresis, or an infusion with the spirit vapor bath "to assist," or in the early stage of a malarial fever, when the patient " ached in every bone," to relieve pain—boneset it was called and bone-ache it relieved. Again, in rheumatic fever, when the patient would burn one hour and sweat the next, and also in acute rheumatism, when the pain would make him " sweat like a Turk," boneset proved a good remedy. It has not been so extensively used in the small dose, but it will be found valuable in many cases if the indications are observed. I do not believe in substituting it for a better remedy, or using it when Lobelia or Veratrum would serve a better purpose, but when indicated it will give satisfaction. Rhus.—The reader will find a study of Rhus under the head of " Remedies that Influence the Nervous System," and we only need to study it here as it influences the circulation. With a frequent, small, sharp pulse, frontal headache (left orbit), and red papilla at tip of tongue, this remedy will slow the pulse, 46 DISEASES OF CHILDREN. lessen the temperature, relieve pain, and establish secretion. It is true, it is usually administered with Aconite, but if one will give it alone he will find it all-sufficient. Burning of the skin is another very good indication, as is bright eyes. Lycopus. Specific Indications.—The circulation is active, pulse frequent and hard, determination of blood to a part—lungs, stomach, bowels, kidneys—with sanguineous discharge or hemor- rhage, cough with sense of heat or burning in the chest, or sense of " rawness," with irritation. Dose.—R; Tinct. Lycopus gtt. v. to gtt. x., water giv.; a tea- spoonful every one, two or three hours. This remedy is not in common use, and yet will be found of marked value, if the indications as above are followed. We employ it, more frequently, in diseases of the chest in the adult, and especially for active hemorrhage and an irritative cough. In the child, it will be especially a remedy for chronic cough, irrita- tion of bronchial tubes and lungs, and determination of blood to the kidneys. Lobelia.—The full, oppressed pulse is the indication for Lobe- lia as a sedative. It is a stimulant to the circulation, giving power to the heart and arteries, and a better condition of capillaries for the blood to pass through. An enfeebled circulation in the lungs with a sense of fullness and oppression is relieved by Lobelia. Digitalis. Specific Indications.—A small, frequent pulse witli want of power in the heart, is the best indication. A feeble cir- culation in lungs, or elsewhere, with scant urine, may also be bene- fited by this remedy. Dose.—fy, Tinct. Digitalis gtt. v., water giv.; a teaspoonful every one or two hours. Homoeopathic Indications, (3d to 6th decimal).__Very slow pulse; harsh appearance of the face; stools gray or ash color* urine scanty; pulsations of the heart intermit, fainting; ascites* hydrocele; hydrothorax ; jaundice with light colored stools scanty brown urine; great debility; vertigo with trembling ; dimness of vision, dark bodies like flies hover before the eyes.__Ehrmann. Digitalis is not in common use, and has not been studied with the care given to others of this class. But in small doses it will be found an excellent remedy. Much of the Digitalis in market is of poor quality. Of a recent and well cured specimen of the infantile therapeutics. 47 herb, let a tincture be prepared in the proportion of four ounces to one pint of alcohol of 76 per cent. The principal use that I will suggest is, as a stimulant and tonic to the heart in cases of anaemia and feeble circulation. In these cases it is associated with iron, cod-liver oil, and a nutritious diet. Spiritus iETHERis Nitrosi. Specific Indications.—The pulse is frequent but free, the skin inclined to be moist, frequent but scanty passages of urine. Dose.—The dose will vary from, gtt. j. to gtt. x. Usually we add a half teaspoonful to a half glass of water, and give it in teaspoonful doses every hour. It is a little difficult for one who has been thinking of medicine in the ordinary way, and reading regular text-books, to think of Sweet Spirit of Nitre as a sedative. It is strong alcohol contain- ing a portion of nitrous ether, and may be regarded as an alcohol, and as a stimulant, using this term as generally understood. But we have seen that the remedies classed as arterial sedatives are in reality stimulants, that is, they lower the frequency of the pulse by increasing the power of the heart and arteries, and by improv- ing the condition of the capillaries. The practitioner may occasionally use the Spirit of Nitre with marked benefit in simple fevers and inflammations, making it take the place of Veratrum or Aconite. Cactus Grandiflora.—The pulse is irregular, sometimes frequent, occasionally slow; there is a sighing respiration, sobbing, uneasy dreams, from which the patient wakes crying or sobbing; face is pale, eyes expressionless; pain in top of the head ; sense of oppression in region of the heart. Dose.—Rs Tinct. Cactus gtt. v., water giv.; a teaspoonful every one to four hours. Homoeopathic Indications, (3d to 6th decimal).—Heart troubles, where you find a great sense of constriction, as if the heart was firmly grasped by a hand or in a vise; difficulty of breathing, attacks of suffocation with fainting, cold perspiration and loss of pulse; hemoptysis, with convulsive cough; chronic bronchitis, with rattling of mucus; vomiting of blood, hemorrhages from nose, lungs, rectum, or stomach ; oedema of the feet.—Ehrmann. The indications as given above will be a sufficient guide to the use of the remedy. The child is in poor health, pale and inactive; very sympathetic, suffers greatly from slight unpleasantness; sleeps 48 DISEASES OF CHILDREN. in the day, wakeful and fearful at night; appetite variable ; abdo- men full or doughy. It may be a remittent or intermittent fever, threatened phthisis, or they call it worms ; we give Cactus and the patient is relieved. Podophyllin. One would hardly think of Pode>phyllin as a remedy influencing the circulatieui, and yet it does so in a very marked manner. The veins are full, face full, abdomen tumid, tongue full, and the patient complains of giddiness and unsteadi- ness, with stupid headache. As a rule the pulse is full and op- pressed. I have used it with most marked advantage in malarial fevers, in ague, and in inflammatory diseases, and hardly know what would take its place. The reader will notice, however, that nothing is said about " constipation of the bowels," and it makes no difference to us whether they are constipated or loose, if the indications for the remedy are present. It will aUo be noticed that stress is placed upon "fullness of tissue ;" when patients are pinched we never give it. I use a first or second centessimal trituration (one to one hun- dred) in diseases of children, but even the old cathartic dose will prove curative when the symptoms are strongly marked. Hamamelis. Specific Indications.—The veins are full and feeble, varicose, tissues soft, feeble, relaxed, swollen. There is fullness about the anus, prolapsus ani, difficult evacuation of feces, swelling of vulva or prepuce, cedenia of legs, spongy throat, enlarged tonsils, abundant mucous discharge from nose, hemorrhage from atony. Dose.—The distillate of Hamamelis may be given in doses of from one to ten drops, or in the usual way. R; Hamamelis gtt. x., water giv.; a teaspoonful every one to four hours. As a local application it may be used of full strength, or diluted with two to ten parts of water. Homoeopathic Indications, (3d to 6th decimal).—Hemorrhoids bleeding profusely with sensation of soreness, weight and burn- ing in the rectum ; varices protrude and the anus feels sore and raw; stools covered with mucus; the back feels like breaking* restlessness at night; dryness of the mouth; varicose veins hard, knotty, swollen and painful.—Ehrmann. Hamamelis is an important remedy, and when the physician learns to use it he will value it highly. It is an admirable remedy in acute catarrh when secretion is established ; in chronic catarrh INFANTILE THERAPEUTICS. 49 chronic pharyngitis and tonsillitis, when the child's voice is husky or flat; in chronic bronchitis with free secretion ; in mucous diarrhoea, abundant urine but painful micturition; in hemor- rhoids, prolapsus ani, ottorrhoea, sprains, bruises, atonic inflam- mations, etc. Remembering that it strengthens and improves the venous circulation, freeing parts from congestion and giving them tone, we can hardly go astray in its use. Apocynum Canabinum. Specific Indications. — There is oedema of feet, eyelids, or of an inflamed part. The pulse may be frequent and full, or frequent and feeble, but capillary circu- Iatiem is weak. Dose.— R; Tinct. Apocynum gtt. v., water giv.; a teaspoonful every one to four hours. Homoeopathic Indications, (3d to 6th decimal).—General dropsy, hydrothorax, urine high colored and scanty, considerable gastric disturbance, pulse weak and irregular, skin dry and husky, hoarse loose cough.—Erhmann. This is one of our best remedies, and the indications are so clear that no one can go astray—oedema, or even the appearance which a tissue presents when it has been infiltrated with serum. In this as with other remedies it does not make any difference what name the disease has, if the indication is present. We use it with equal advantage in cholera infantum, or in scarlet fever. It lessens the frequency of the pulse, gives a better cir- culation of blood, stimulates all the secretions and improves nutrition. If I notice in scarlet fever a fullness of the eyelids, or swelling of the feet, I give Apocynum. If in measles there is difficulty in breathing with a harassing cough, and the face or feet are puffy, I give Apocynum. So I would in croup (inspiration diffi- cult), in infantile remittent fever, in inflammatory diseases, in rheumatism, or in any chronic disease. REMEDIES THAT INFLUENCE THE TEMPERATURE. Baths, Veratrum, Acids, Food, Rhus, Alkalies, Air, Gelseminum, Cod Oil, Exercise, Bryonia, Phosphorus, Aconite, Baptisia, Sulphur. Among the means employed in the treatment and cure of elis- ease, there are none of greater importance than those which 4 50 DISEASES OF CHILDREN. rectify wrongs of temperature. The reader will recall the fae-t that a temperature of 98° is essential to health, and the perform- ance of healthy function. Even with but a slight variation the person is ill, and the illness is in proportion to the amount of change. If the temperature falls below the normal standard, every function is impaired—the blood is not circulated well, respiration is feeble, appetite and digestion impaired, nutrition bad, and waste and excretion are imperfect. If the temperature is increased the pulse is more frequent, the nervous system ex- cited, (it may be wrong in kind or oppressed), the appetite lost, digestion imperfect, nutrition arrested, waste and excretion diminished, and changes of the blood go on more rapidly. The body thermometer is one of our most certain means of diagnosis, and can not be dispensed with by any one who wishes certainty in practice. It measures the intensity of diseased ac- tion, and determines for us the gravity of disease, and the danger of a fatal termination. It is a little more difficult to use with children than with adults, but there is hardly a case that the temperature can not be taken at the axillae. In studying the means that regulate the temperature it may be well to recall something of the physiology of heat production, and the means that nature provides to maintain this constant temperature of 98°. The heat is furnished by the combustion of food, and there are two, possibly three, elements here to be taken note of: (a) the quality, quantity and preparation of the food ; (b) the introduction of oxygen by respiration for combustion ; (<■) the presence in the blood of certain materials (phosphrus, sulphur, etc.,) which may be regarded as excitants of combustion. If a sufficient quantity of food is not taken the body is burned to supply the necessary heat. If the body is burned, the person suffers the excitation of burning. The temperature is regulated, in so far as the production of heat by combustion is concerned, by the ganglionic or sympa- thetic system of nerves. It is also regulated by the skin which serves as a safety-valve for the body—opening to allow the escape of heat, when it is produced in too great quantity and closing to retain it, when produced in too small quantity. Our remedies influence the temperature in both these ways • we con- trol the processes of combustion through remedies influencing the ganglionic nerves, influencing the circulation, respiration and combustion; we influence the skin so as to put it in better condi- INFANTILE THERAPEUTICS. 51 tion for its work, increasing secretion and respiration for the removal of heat, stimulating it and giving it tone so that heat may not escape. Baths. The importance of baffhs in the treatment of disease has been clearly shown in the past fifty years, so that but few will dispute their advantage, though in practice they may not use them. I think that the success of our school of medicine has depended as much upon our knowledge of bathing—the water cure—as upon the administration of drugs. From the days of Beach we have been using cold baths, hot baths, alkaline baths, acid baths, tonic baths, stimulant baths, vapor baths, general baths, local baths, baths to reduce the temperature, to stimulate the skin and increase the temperature, to promote elimination, to increase the respiratory function, etc. The Cold Wet-Sheet Pack is not used as frequently as it might be because people do not like the first impression of cold, and are afraid of it. In young children the nervous excitement from the shock is sometimes injurious, but if well borne, and there is a vigorous circulation with increased temperature, its action is very kindly. A sheet is wrung out of cold water and spread upon the bed, the little fellow is undressed, lain upon and wrapped up in it. Blankets and comforts are spread over and tucked in, and in a few minutes an agreeable warmth takes the place of the first impression of cold, the skin is moist, the pulse conies down, nervous excitement and pain pass away, and presently the child sleeps sweetly. It is allowed to remain in the pack for one hour, when the body is rubbed thoroughly dry, and dry clothing is put on. The local cold pack may be employed in acute inflammation, with an active circulation, in pharyngitis, laryngitis, croup, in- flammation of bronchia or lungs, inflammation of bowels, etc. A towel wrung out of cold water, and covered with dry flannel, is a very good way to use it. The indication is an increased temperature with an active cir- culation. The Hot Wet-Sheet or Blanket Pack is employed when the skin is enfeebled and inactive, especially in the eruptive fevers, and in local inflammations when the circulation is feeble. In measles, scarlet fever, or smallpox, the eruption fails to make its appear- 52 DISEASES OF CHILDREN. ance at the proper time, the nervous system is oppressed, there is tendency to coma, and the skin sheaws a feeble capillary circula- tion. Here a hot blanket pack, using the water as hot as it can be borne, is attended by the best results. The local hot pack is useel in acute inflammations when the life of the part is impaired and the circulation is feeble. We thus use it in sore throat, in croup, in inflammations of the respiratory apparatus, in diseases of the abdominal viscera, local inflamma- tions, etc. To determine whether a bath, either a pack or hand-bath, shall be hot or cold, is important, and we are guided by this : If the circulation is active and the temperature increased, it will be cold ; but if the circulation is feeble, it is to be hot. A hemorrhage, or an abundaut discharge of mucus or pus, or an increased secre- tion, is best treated with the hot local or general bath. Simply Sponging the surface with water lowers the temperature by evaporation, and puts the skin in better condition to perform its function. We thus use it several times in the day when per- sons are suffering with fever and carrying a high temperature. When necessary soap is used for the purpose of cleanliness. The Alkaline Sponge Bath is one of the old Eclectic means, and a very important one. Originally it was broke water, wood ashes being used in sufficient quantity to make the water slightly slip- pery to the touch; after this pearlash or bicarbonate of potash was used in place of the ashes. In more modern days soda has taken the place of potash, and now the alkaline bath is a soda bath. The " broke water" or potash was decidedly the best in the majority of cases, its action upon the skin being kindlier, leaving it in better condition. When I speak of the alkaline bath, I wish to be understood as recommending water made alkaline with potash. If one is in doubt whether the sponge bath should be alkaline or acid, he will do well to note the indications as presented by the tongue. If the tongue is broad and pallid the bath should be alkaline; if red, especially if deep red, it should be acid. TJie Acid Bath (water acidulated with vinegar) will be found to exert a very pleasant influence upon the skin, when indicated leaving it soft and in better condition to do its work. The alka- line bath may have been used, leaving the skin dryer and harsher than it was before, whilst the acid bath gives relief. The child's face and head are hot and dry, and the ordinary use of water does no INFANTILE THERAPEUTICS. 53 good-, it is sponged with vinegar and water and is relieved, and presently sleeps. In some rare cases we use water acidulated with muriatic acid; in a larger number, especially where the symptoms are typhoid, and it is almost impossible to keep*the child free from unpleasant odors, we use sulphurous acid. Fatty Inunction is a most important means of putting the skin in better condition and rectifying the wrongs of temperature. Se)inetimes we use lard alone, the child being thoroughly rubbed with it, and then rubbed clean with soft flannel. In some cases we add quinine to lard, 5ss. to 3j. to gij., especially when there is a malarial influence, or when we wish to stimulate the brain or spinal cord. In other cases when stimulation is wanted, oil of cinnamon, cloves, or eucalyptol, is added. In scarlet fever we sometimes use a "bacon rind," or a pre- scription of creasote and salt with lard, as a stimulant to the con- gested skin. It lowers the temperature, improves the circulation, gives better functional activity, and favors the appearance of the eruption. In malarial or typho-malarial fevers I have seen the inunction of quinine lower the temperature two degrees in as many hours, lessen the frequency of the pulse, and in a short time arrest the disease, when quinine internally had not only failed to do good, but had proven harmful. In cholera infantum, especially if attended by fever, the quinine inunction is one of our most important remedies. We use inunction in chronic disease when innervation is fee- ble, the appetite and digestion poor, nutrition imperfect, and skin atonic. In some cases it exerts a very salutary influence, and patients improve from the commencement of the rubbing. The Stimulant Bath is occasionally useful when the circulation is feeble. It may be a mustard-water pack, when there is sudden and great prostration ; quinine with proof-spirit when there is a malarial influence; or an infusion of Xanthoxylum, Polygonum, or remedies of like character. Tonic or Astringent Baths are employed in some cases where the skin is atonic and the circulation is feeble. An infusion of Hydrastis may represent the first, and of Quercus rubra the second. 54 DISEASES OF CHILDREN. Food.—It might be thought that a study of fe>ods would come more appropriately elsewhere, anel we will have occasion to notice them again under the heading, Restoratives. But heat is set free by the oxygenation of food, or of tissue, its only sources, so far as we know. Fooels are calorifacient or heat-producing, and histe)genetic or tissue-making. The first contains no nitrogen, the second contains nitrogen. The first may be represented by sugar and starch; the second by the albumen and gluten of vege- table substances, and the albuminoid and muscular tissues of animals. The majority of foods are in part calorifacient and in part his- togenetic, and we determine their value in tissue-building by the per centage of nitrogen in them. When this is low, the food is principally heat-producing, where it is large the food is eminently tissue-making. For the child, milk contains these elements in the best proportion, though we use a starchy food, or fat, when heat is especially wanted, or beef tea when a stimulant, tissue- making feiod is wanted. If a child is carrying a high temperature in fever and inflam- mation, and is taking no food, the body is burned to supply the heat. The body can not be burned, even slowly, without irrita- tion of the nervous system and suffering. I am sure that this will account, many times, for the restlessness, sleeplessness, and final wearing out of the nervous system in febrile and inflamma- tory elisease. One of the maxims of a rational practice of medicine is__to keep the stomach in such reasonably good condition that a por- tion of food may be taken and digested, and we look as carefully after the food of the sick as their medicine. In many cases we find that if we relieve a temporary irritation or atony of the stomach, so that the chilel can take a moderate amount of milk or other food, the temperature comes down and the irritation of the nerve centers passes away, and the child rests and sleeps. By giving food we supply the materials for combus- tion, anel save the tissues of the body. In some cases of chronic disease, we will observe a deficient temperature, or the heat is not properly distributed, the feet and hands being cold. In such cases a supply of such calorifacient food as may be digested, not only furnishes the 98° of heat which is an essential condition of life, but such other force as mav a* 1 nutrition and give the force necessary for exercise. INFANTILE THERAPEUTICS. 55 Air. Air is usually studied as a condition of healthy life, and as a cause of disease, but if a condition of life, then it must prove a remedy in some cases of disease. A certain amount of air taken through the respiratory apparatus is necessary for combustion and heat production, and if patients are not supplied with it they must suffer. We place stress on the necessity for good ventilation—a sufficiently free admission of air to the apartment, and a current of air from it, usually by means of an open fire. The open air is necessary for a cure in some cases of chronic disease in children, as it is for the adult. If the little patients can have that moderate exercise which calls into action the respi- ratory apparatus, it is so much the better. A dry air, from stove heat, is sometimes so irritant that it ex- cites the nervous system, increases the frequency of the pulse, and will increase the temperature. A very moist atmosphere maybe so depressing that the functions of life are feebly performed, anel we will be obliged to rectify this if we cure the patient. Again, the air may be so loaded with dirt, or unpleasant gases, that it will not sustain life, and in severe cases is absolutely poisonous. A cure comes in such cases from free ventilation, cleanliness, and the use of agents which change or destroy the unpleasant mate- rial, as chloride e)f lime, chlorinated soda, sulphurous acid, etc. Exercise. As we have just seen, where the respiratory move- ment is feeble, the processes of combustion go on slowly and a sufficient amount of heat is not produced. In aeldition to this, the burning of waste material and old tissues is not properly per- formed, and the body and blood are loaded with effete material. We find some chronic diseases of children where the exercise that a child will get, if a rug is thrown upon the floor and it is allowed to tumble around upon it, is better than medicine. In the neighborhood of the sea, children are sent to the sea- shore and allowed to roll on and dig in the sand. In cities nurses take children to the parks and allow them to make sand and gravel houses or fortifications of the gravel walks. What we want to know in these cases is, that every effort should be made te> induce the child to play and amuse itself, and thus get the ne- cessary exercise, and that nursing in the anus is the worst possible wav to obtain good health. But the knowledge of when rest is necessary is just as essential. Rest to body, rest to nervous system and sleep, are essential in the treatment of diseases which have a high temperature. Restless- 56 diseases of children. ness and want of sleep are almost certain to increase the tempera- ture; even the continuous fretting of a sick child for something it wants, or for its mother, will send the thermometer up one or two degrees. A part suffering from inflammation needs rest, sometimes the absolute rest that we get by the use of a splint. We arrest the progress of a morbus coxarius, or a disease of the knee joint by a plaster of Paris or other dressing which will give absolute rest. A flannel bandage so nicely adjusted that it will support the abdomen well, is sometimes one of our best prescriptions for cholera infantum. Aconite. This remedy has been twice studied, but it will do no harm to look at it as a remedy influencing the temperature. We have already noted the relation between the pulse and the temperature, an increase of one degree of heat for each ten beats of pulse. If the pulse is lessened in frequency by remedies the temperature comes down, and vice versa. All arterial sedatives are therefore thought to lessen the temperature, when above the normal standard, and this is especially true of Aconite and Veratrum. But this remedy influences the functions of calorification di- rectly through the ganglionic and respiratory nerves. We have been in the habit of thinking that it always lessens heat pro- duction, and it very certainly does so in many cases when the temperature is too high. But if one will administer the remedy in a case of congestive chill or cholera, when the pulse is small and running over one hundred beats per minute, he will see it increase the temperature, and parts that were cold regain their heat. Veratrum. This, like the preceding remedy, has a direct influence upon the function of calorification, both as it influences the circulation, respiration and combustion All these are too active and characterized by strength, and Veratrum lessens the excitement and the activity. When indicated it will frequently ]e>wer the temperature from one to three degrees in twelve hours and in minor diseases, like the febricula, or at the commencement of inflammations, it may bring it down to the normal standard in a very short time. Its influence in superficial inflammation, when topically ap- plied, is sometimes so marked as to excite surprise. The irrita- infantile therapeutics. 57 tion is relieved, determination of blood is arrested, and the tem- perature falls in a short time. Rhus. We have studied Rhus as a remedy influencing the nervous system, but its influence in controlling the temperature is not to be neglected. It allays irritation of the nerve centers, especially of the ganglionic system, and slows the process of combustion. In the larger number of cases, when indicated, it markedly reduces the temperature; indeed its action in this direc- tion is quite as marked as any remedy of the materia medica. Bryonia. This is another remedy that lessens the function of calorification, (when the temperature is high,) by relieving irritation of the ganglionic nerves, and possibly by its action upon the blood. It will be remembered that pain is one of the principal indications for Bryonia, and pain is the evidence of unrest. Gelseminum. Gelseminum lessens the temperature by allay- ing cerebro-spinal irritation which is back of ganglionic excite- ment. When indicated by flushed face, bright eyes and contracted pupils, its influence is very marked in this direction. Baptisia. This remedy is fully studieel under the head of Antiseptics, but it also exerts a marked influence in lowering the temperature when above the normal standard. Like other remedies it requires the special indications—the full purplish face, like one who has been exposed to severe cold, and a bluish-red tongue. In this case the high temperature is dependent, in part, upon a peculiar sepsis, and this being antidoted the temperature falls rapidly. I have seen it come down, under the influence of Bap- tisia alone, from 106° to 100° in twenty-four hours. Acids. Specific Indications.—The tongue is dusky red or deep red, and frequently small; mucous membranes and sometimes the skin show the same color. The coatings of tongue and sordes upon the teeth brown, growing darker as the disease progresses. Dose.—Usually we order muriatic acid 3>-, water, syrup, aa. gi.; add to water so as to make it pleasantly acid, and give as patient will take it. In some cases a sharp sparkling cider is used and given a teaspoonful to a tablespoonful in water every three or four hours. In other cases an acid whey (lactic acid) will be taken bv the patient, whilst the others will be rejected. The truth of specific medication is well illustrated by the action of acids and alkaline agents in the cure of disease. That 58 DISEASES OF CHILDREN. they are curatives no one will dispute; that they act equally well in the same cases, or that they can be taken by chance and get uniform ge>od results, no one will claim. If they are to be use'd at all we must have some means of determining when we shall use the one, and when the other. I determine this by the color of tongue, and where blood shows freely as in mucous mem- branes and some portions of the surface. If the color is deep or dusky red, an acid is wanted ; if it is pale, pallid, the patient requires an alkaline salt; if neither the patient requires neither. the one nor the other. If any one has a better means of deter- mining these points, then the better light should be followed ; if not we will continue to be guided by the color. When indicated the acid exerts a marked influence in lessening an exalted temperature, anel will sometimes reduce it when seda- tives and baths have wholly failed. This is especially true when typhoid symptoms are present, as the acid antidotes the process of sepsis. Thus in England and on the Continent, the continued fevers have been treated with acids alone, (diet, rest and good nursing added,) in thousands of cases with most marked success, the mortality being reduced in some cases to two or even one per cent. If we can give our little patients a pleasant acid drink in place of the nauseous drugging of the olden time we should be thankful. Not only is the acid of advantage when given internally, but the acidulated bath is a means not to be neglected. There are cases when the ordinary bath or the alkaline bath seems to make no impression upon the skin or the temperature, but when a little vinegar added to water is refreshing and cooling, the hot face and head sponged with vinegar and water have given relief, the irrita- tion is quieted and the patient sleeps. The tense, hot abdomen with skin like parchment, is softened, cooled and relieved etf irritation by an acid bath or pack. It will not do to ne<>lect the "small things" in the practice of medicine. Alkaline Salts. Specific Indications.—The tono-ne is broad and pallid, and its coatings are white and pasty. Dose.—If there is no special indication fen* another we will employ a salt of soda, for soda is the salt of the blood. We add it, usually the bicarbonate, to water in such quantity as will make a pleasant drink, and let the patient take it freely. If there is marked muscular debility we use a salt of potash in place of the soda. INFANTILE THERAPEUTICS. 59 If there is a tendency to subcutaneous inflammation, or inflam- mation and suppuration of cellular tissue, lime-water or sulphite of lime is to be given. The indications for the use of the alkaline salts are so clear that no one can mistake them. Why they should lessen the temper- ature (when in excess) as do the acids, is more than we can say with our present knowledge; only this, that they correct a wrong of the blood and the fluids of the body, anel righting this wrong, they remove the nervous and vascular excitement which was caused by it. The one thing in therapeutics that we can not have impressed upon us too forcibly is, that the prominent lesion, as indicated by those symptoms that point us to remedies, is very frequently the basis of the disease, and if taken away the entirety of the disease passes away of itself. In our Western country, and where malarial diseases prevail, the alkalies are much more frequently indicated than the acids; indeed, in some seasons diseases are cured by these alone. I re- call a year of malarial fever in which sulphite of soda or chloride of sodium was more certain than quinine; indeed they woulel cure ague when quinine had failed. In rheumatic fever this is also the case in some seasons, and the indications for the alkaline salts being marked, they cure rheumatism. Phosphorus. Specific Indications.—-Phosphorus is indicated by a low temperature, cold extremities, doughy or waxy skin, enfeebled nutrition of the nerve centres with want of innervation, sensation of weight and pressure in peritoneum and pelvis, irri- tation of urinary passages and burning on passing urine. Dose.—The tincture of phosphorus is used in low grades of inflammation of the respiratory apparatus, in disease of the pros- tate, bladder and urethra; the hypophosphites to improve waste and excretion, and to aid blood-making and nutrition. The phosphites are used to aid digestion (laxative) and to favor nutri- tion.—R; Tinct. Phosphorus gtt. v. to gtt. x., water giv.; a tea- spoonful everyone to four hours. Hvpophosphite of lime gr. J to gr. j., everv four hours. Phosphate of soda gr. j. to grs. ij., twice or three times a day. It will be noticed from what has been said above, that phos- phorus has an extended use in medicine, but it must be employed with care. I employ the tincture in diseases of children but 60 DISEASES of children. rarely, selecting those cases where there is an atonic condition of the respiratory apparatus, or where there is disease of the bladder and urethra. To stimulate calorification, and increase the production of heat, and also to burn waste material, I prefer the hypophosphites. The hypophosphite of lime is preferreel where there is tendency to deposit of tubercle or disease of cellular tissue; the hypophos- phite of soda when the tongue is broad and pallid, and a salt of soda would be given. The compound syrup of the hypophosphites is sometimes useful both to increase calorification and to aid nu- trition. Cod Liver Oil. Specific Indications.—The extremities are cool; the skin relaxed, doughy or dirty; tongue dirty at base; bowels irregular; pulse lacks strength ; small boils; inflammation of cellular tissue; ulceration of the skin; bad blood. Dose.—The dose of cod oil for a child will vary from one-half to two teaspoonfuls three times a day. A pure inodorous oil will frequently be taken without difficulty. The indications given above will point out the cases which will be benefited by cod oil. The processes of combustion do not go on well, the waste of tissue is not burned as it should be, and fitted for excretion, and the blood is loaded with it. This impairs the new blood that is making, the new tissues which are building, and enfeebles all the functions of the body. In this way the pa- tient grows the conditions which give cacoplastic and aplastic deposits. In some cases all the functions seem to be stimulated bv the administration of the oil. The skin becomes clean and active the appetite improves and digestion is better, and there is an increase of tissue. Quinine. We have already made a full study of quinine un- der the head of Remedies which Influence the Nervous Svsteni and we will only consider it here as it influences the temperature. It was shown by Prof. I. G. Jones, that in the purely malarial fevers—uncomplicated—this remedy could be administered with the effect of lowering the temperature, diminishing the frequency of the pulse, and establishing a complete intermission of the fever, if not arresting it. In the remittent fevers of the Scioto valley the administration of quinine would commence as soon as the highest point of fever was passed, and then repeated every three hours, there would be a marked abatement of the disease. INFANTILE therapeutics. 61 In diseases of children in malarial regions, the action of qui- nine is frequently desirable. The temperature is high, the pulse frequent, the secretions checked, and we are sure of the periodic character of the disease—the proper quantity of the remedy as an antiperiodic is given in divided doses, and the fever is arrested. In the very minute dose, or when used by inunction, it will sometimes exert a very marked influence in controlling the tem- perature, even when the disease is not malarial. We do not wish to recommend it, however, when other remedies are indicated, for it is used far too frequently now, and to the injury of many pa- tients. Nux Vomica. This remedy has been fully studied elsewhere, and we have only to notice it here as a stimulant to the respira- tory system, and an excitant of calorification. In cases where there is enfeebled spinal innervation and consequent respiratory function, nux or strychnia will be thought of as remedies. Sense of oppression about the praecordia, increased difficulty of respi- ration when asleep, tendency to retention of urine, slow move- ment of the bowels, and nausea, are indications. Stimulants. There are a few stimulants which can be used with advantage to stimulate heat production, but their use is lim- ited. Alcoholic stimulants are very rarely used in diseases of children, and possibly the only cases in which we would think of them is in the slow convalescence from acute disease. I am sure that their use during the progress of fever or inflammation is in- jurious. A teaspoonful of brandy or good whisky in four to six tablespoonfuls of water (hot or cold, as suits the patient best) sweetened, sometimes is a good form. Tinct. Xanthoxylum may be used occasionally, as may a Tinct. of Asarum, or once in a long while the Comp. Tinct. of Cajeput. Probably the best child's stimulant will be found in the old mix- ture: R) Comp. Spirits of Lavender 5'nj-, Tinct. Lobelia 5h, water and syrup giss. Mix. This stimulates the respiratory nerves, improves the circulation, and gives an agreeable sense of warmth. Salicylic Acid. Salicylic acid will be studied under the head of Anti-rheumatics. Here we wish only to note its effect in diminishing the temperature of the body. As yet we know simply the fact that it has this influence in some cases, but in what particular cases, and what the specific indications are, we do 02 DISEASES OF CHILDREN. not know. I should say that the best effects are to be expected when the patient suffers considerable pain in the extremities, and when, though the temperature is increased, the skin is inclined to be moist. Salicin. This remedy stands between quinine as an anti- periodic and salicylic acid as an anti-rheumatic, and may be thought of when with periodicity there is pain of a rheumatic character. In such cases it will lessen the heat of the body. Nitric Acid. This remedy will be fully studied with the next class, though it is difficult to properly classify it. When indi- cated—violet colored tongue—it will lessen the temperature in a very marked manner in cases of fever or inflammation, and in malarial fever will prevent the recurrence of the exacerbations. In slow infantile remittents, when the pulse has a range of 100° to 102°, I have occasionlly seen the most marked benefit from its administration. REMEDIES WHICH INFLUENCE THE RESPIRATORY APPARATUS. The function of respiration is one of the most important in the economy, and the organs engaged in it may be regarded as almost the center of life—in the olden times classified as " noble organs." Through this apparatus the blood receives its supply of oxygen, and is freed from carbonic acid gas. It is inti- mately associated with the circulation, both in its structure and its innervation, and has sympathies with the entire bodv, Remedies influence the respiratory apparatus and its function directly, as they influence other parts of the body, and a study of them in this relation can not but be profitable. The principal of these are :— Aconite, Stillingia, Senega, Veratrum, Lycopus, Scillae, Bryonia, Drosera, Sticta, Ipecacuanha, Sanguinaria, Rumex Lobelia, Euphorbia, Grindelia Phytolacca, Phosphorus, Nitric Acid ■* Eupatorium Perfoliatum, Aconite. We have made a study of this remedy two or three times, and need but note here its direct influence in relievino- irritation and controlling inflammation of this apparatus It hi a direct action upon the tonsils, and will sometimes arrest INFANTILE THERAPEUTICS. 63 quinsy, if used in the early stage. It is our best remedy in laryngitis or croup, giving results that can not be obtained with the old nauseant or emetic treatment. In mucous croup I rarely think of using any other internal remedy, and in the pseudo- membranous form it will be one of the most important. In acute bronchitis and in pneumonia it is the sedative usually indi- cated in childhood, and forms a part of a good treatment. Veratrum. Veratrum is the remedy selected when the pulse is full and frequent, and its action is direct in arresting inflam- mation of any part of the respiratory apparatus. It controls irritation of the pneumogastric, allays cough, and improves the respiratory function. Bryonia. This remedy influences the pleura and parenchyma of the lungs, lessening irritation and arresting the inflammatory process. It is indicated by pain in the chest, sense of soreness, with catching pain on inspiration, pleuritic pain, and a short harassing cough. The flushed right cheek is a good indication. It is one of our most important remedies in this relation, and will be in frequent demand in bronchitis, pleuro-pneumonia, and in pleurisy. Ipecacuanha. Ipecacuanha exerts a specific action in reliev- ing irritation of mucous membranes, and we employ it in the first stages of bronchitis and pneumonia with the most marked benefit. In years past I have treated infantile pneumonia with Ipecac alone with much success. It was rubbed up with sugar, anel given in doses of one-fourth to one grain, sometimes pro- ducing slight nausea. Now we use the tincture, combining it with Aconite, the proportions being—P^j Tinct. Aconite gtt. iij., Tinct. Ipecac gtt. v. to gtt. x., water giv.; a teaspoonful every hour. Lobelia. This remedy exerts a very marked influence upon the respiratory apparatus, improving the innervation and circu- lation. The indication is—an oppressed respiration, congestion, increased mucous secretion, moist blowing sounds, mucous rattling in the chest. AVhen patients are old enough to complain it is of a sense of weight and oppression, especially about the praecordia. The most marked benefit is obtained when there is a tendency to congestion, and when the respiratory tubes are filled with mucus. In asthenic bronchitis, when the child breathes with 64 diseases of children. great difficulty, and the rattling of mucous can be heard all through the chest, I know of no remedy so certain to give relief. It is also one of our best remedies in infantile asthma. In ordinary practice we use it with the sedatives, gtt. v. or gtt. x. of a tincture of the seed being added to water giv. In asthenic bronchitis and in asthma, I frequently make the del prescription. 1^ Tinct. Lobelia (seed) 5j-> Comp. Spts. Lav- ender 5'ij-, Syrup giss. Mix. Give in small portions, frequently repeated, just short of nausea. This will be found an admirable form for the remedy, as it is readily taken, is kindly received by the stomach, and it relieves nervous irritation and gives rest. A description of Lobelia would not be complete without refer- ence to its old use as a nauseant. For this use in diseases of children, I prefer the acetous tincture to other preparations. It is prepared in the proportion of four ounces of the herb lobelia to the pint of dilute acetic acid, or vinegar; or the acetous tinc- ture may be formed into a syrup by the addition of two pounds of sugar to the pint. Given in nauseant doses, lobelia relaxes the respiratory pass- ages, and thus gives temporary ease to the breathing. In croup, in asthma, in bronchitis, and in whooping-cough, this action is very important. Continuing this nauseant influence there is increased secretion from the mucous membrane of the respiratory passages, and it is thinner and less tenacious than the secretion during the inflammatory process. The engorgement of the vessels is somewhat relieved by the secretion, and the mucus is removed with greater ease. In administering the nauseants for this purpose, they should be repeated so frequently as to keep up a continued action ; for if given at long intervals, the alternation of relaxation and de- termination of blood proves injurious; and to obtain this actum, they should never be given to produce speedy emesis; indeed emesis is not desirable in any case, unless to remove accumula- tions of mucus already secreted. Eupatorium. When the pulse is frequent, full and free, and the skin inclined to be moist, the Eupatorium will be found a good remedy in bronchitis or pneumonia. Phytolacca. This remedy exerts a special influence upon the fauces and pharynx-—the throat—and when this is inflamed or infantile therapeutics. 65 irritated, and is a source of cough or respiratory difficulty, we think of Phytolacca. A pallid tongue with red spots, sore mouth, sore throat, enlarged lymphatic glands or sen-eness or pain of mammary glands, associated with disease of the respira- tory apparatus, call for Phytolacca. Stillingia. Specific Indications.—Sense of rawness and tick- ling in the throat; sense of irritation behind the fauces or the velum pendulum palati; burning, itching of the larynx, which causes a short cough and inclination to hawk and free the throat; croupal cough and voice. Dose.— ly Tinct. Stillingia gtt. x., Simple Syrup gij., one- femrth to one-half teaspoonful. I like the Linamentum Stillingia (R5 Oil of Stillingia oij., Oil of Cajeput oh, Oil of Lobelia 5ss., Alcohol gj. Mix) in doses of one-half to one drop on sugar. Stillingia is one of our best remedies for the relief of cough, when it is caused by a sense of irritation of the throat. Wc use it in chronic bronchitis, in acute bronchitis when secretion is established, and especially in laryngeal disease, and croup. Even the external application over the larynx will cure croup, anel is much safer than the old treatment. Usually I administer Aconite internally and apply the Stillingia liniment to the throat. Lycopus. The pulse is frequent and somewhat full or hard, the cemgh paroxysmal, expectoration of muco-pus, difficulty in urination, hemorrhage from lungs or kidneys, deposit of tubercle. Dose.—As a cough medicine I administer it in drop doses on sugar; for other purposes—Rj Tinct. Lycopus gtt. x. to oij., Alcohol gss., water giijss ; a teaspoonful every one to four hours. I like the action of Lycopus very much in chronic bronchitis, pneumonia, or tendency to phthisis pulmonalis. It relieves the cough, quiets pain, gives rest, diminishes the temperature, and brings the pulse down to a normal standard. It will also give good results in chronic inflammation of the kidneys, bladder and urethra. Sanguinaria. Specific Indications.—A sense of burning and constriction in the fauces or pharynx, with irritative cough and difficult respiration. The patient is nervous and restless, redness of nose with burning and thin acrid discharge, spots of bright redness on face or on chest, redness and burning of the ears. Dose.—The dose will depend upon the action wanted. Many 5 66 DISEASES OF CHILDREN. times I use it in very minute doses—!Rs Nitrate of Sanguinaria gr. ss, water iv.g; a teaspoonful every two or three hours, (or Tinct. Sanguinaria gtt. ij. to gtt. v., water giv.) In other Cases I would use the acetous tincture in full doses to nausea for a tem- porary effect. Homoeopathic Indications, (3d to 6th decimal).—Congestion of blood to the head, with ringing in the ears and flushes of heat. Sick headache, beginning in the morning with vomiting of bile, worse from motion, stooping, noise or light. Periodical headache. Coryza, with loss of smell. Nasal catarrh. Nasal polypus. Ulcerated sore throat. Tongue feels sore as if burned, coated white. Sensation of emptiness in the stomach soon after eating. Croup. Asthma. Pneumonia with very difficult respiration, cheeks and hands livid, pulse soft and easily compressed.— Ehrmann. Like the Lobelia, for the old use, I prefer the acetous tincture of sanguinaria to any other preparation. It is prepared with two ounces of the ground root to one pint of dilute acetic acid, or vin- egar. A syrup may be prepared in the same manner as named for the Lobelia. Sanguinaria is rarely used alone; but in combination with Lo- belia it gives us our most efficient nauseant expectorant, and is the remedy we prefer in cases of mucous and pseudo-membranous croup. In small doses, so that it does not produce nausea, it be- comes a stimulant expectorant, and will check secretion from the bronchial mucous membrane. Nitrate of Sanguinaria. The nitrate of sanguinaria is one of the few really good concentrated preparations. It is rarely used in the form of powder, being too acrid; but, combined with simple syrup, in the proportion of one grain to four ounces it furnishes a very desirable remedy. Its action is rather that of a stimulant to the respiratory apparatus, and it should not be used in nauseant doses. The dose of the syrup will be ten drops for a child two years of age. Euphorbia. This remedy, which is fully studied with those which influence the digestive apparatus, has an action very much like ipecac, and may be used to quiet irritation of the bronchial tubes and to check profuse secretion. Dose.—!fy Euphorbia Hypericifolia gtt. v. to gtt. x., water giv.; a teaspoonful every hour. INFANTILE THERAPEUTICS. 67 Phosphorus. This remedy, which has been fully studied in other relations, iuflueuces the respiratory apparatus in a direct manner, stimulating a better innervation and circulation. It may be prescribed in low grades of inflammation of the lungs and bronchia in minute doses as—R; Tinct. Phosphorus gtt. j. to gtt. iij., water giv.; a teaspoonful every hour. Senega. Specific Indications.—The cough is deep, succussive; much rattling in the chest; free expectoration of mucus, or muco- pus; skin is harsh and dry and the epidermis desquamates, or it is relaxed and the surface looks dull and dead. Dose.—The Syrup Senega may be used in doses of one-fourth of a teaspoonful, as a stimulant to the respiratory apparatus. Or the tincture may be employed, as—R; Tinct. Senega gtt. v. to gtt. xx., water giv.; a teaspoonful every one to three hours. The stimulant influence of Senega upon the throat and bron- chial mucous membrane is well known, and is probably its most important use. For this purpose I prefer to use it in the form of tincture to that of syrup as commonly employed. In chronic bronchitis with profuse secretion, it may be combined with small doses of Ipecac and Veratrum. Its influence upon the kidneys and reproductive organs needs to be studied, and I have no doubt some important uses will be found for it. I have employed it in squamous disease of the skin, and like its action very much ; it is one of a very few remedies that influence these diseases. * Scill.e. Specific Indications.—Cough with secretion of a yel- lowish muco-pus, mucus rattling in the chest, scanty urine, feeble circulation. Dose.—R< Acetum Scillae gss., Syrup giss.; from one-fourth to one-half teaspoonful every one to three hours. Homoeopathic Indications, (3d to 6th decimal).—AVhooping cough, sounding loose, with sneezing and watering of the eyes \ and nose. Catarrhal affections, with loose sounding cough ; more expectoration in the morning. Wheezing breathing. Pneumo- nia. Pleurisy. Asthma. General anasarca. Hydrothorax. Fre- quent desire to urinate, with profuse discharge of pale urine.— Ehrmann. Sticta. Specific Indications.—The patient complains of pain in the shoulders extending to neck and back of the head; the QS diseases of children. chilel will be observed to draw its shoulders upward, throw the heael backward and move it uneasily. There is a harsh, dry cough, evidently from irritation and not to remove secretion. Dose.—R< Tinct. Sticta gtt. v., water giv.; a teaspoonful every one to three hours. Homozopathic Indications (3d to 6th 'decimal.) Dry coryza, with constant desire to blow the nose. Chorea, constant invol- untary motion of the feet. Excessive dryness of the nasal pas- sages and soft palate; deglutition painful on this account. Dry, hacking cough.—Ehrmann. Sticta is a very fine remedy when the indications are clear as above. Why a pain in the shoulders, neck and to occiput, call for sticta, is more than I can tell, any more than I can tell why a sick person should have a pain in his shoulder and back of neck and head. But all we want to know in medicine is, this relation between a definite symptom or symptoms, and the curative ac- tion of a remedy. Sticta is an excellent remedy for cough, re- lieves irritation, and improves respiration, acts kindly upon the stomach, anel is one of our best anti-rheumatics. Rumex. Specific Indications.—Cough with sensation of full- ness in the chest, sighing, yawning, efforts to take a full inspi- ration. Dose.—P>« Tinct. Rumex gtt. v., water giv.; a teaspoonful every one to three hours. We employ Rumex in cases of bad blood, with disease of the skin; in such cases it is certainly one of the most valuable alter- atives we have. In these cases we not only use it internally, but as a local application. In scrofulous disease, with deposit in glands and cellular tissue, with tendency to break down and fee- ble repair, I think the Rumex unequaled. Here, also, we use it internally and locally. Grindelia. Specific Indications.—The breathing is labored and asthmatic; the cough hard with rattling of mucus • sense of soreness and rawness of chest; chronic ulceration, with feeble venous circulation. Dose.—R; Tinct. of Grindelia 3j-, Glycerin, Svrup aa. gj. • one- fourth to one-half teaspoonful every two or three hours. Grindelia may be employed as a cough lemedy in fleshy chil- dren with feeble circulation, and in asthma with secretion but infantile therapeutics. 69 want of power to expectorate. It is a stimulant to the respira- tory apparatus and to the respiratory function. Locally (in the proportion of gj. to water Oj.) it may be used in the cure of old ulcers, scrofulous ulcers, and as a means of discussing scrofulous enlargements. Hypophosphites. The compound syrup of the hypophos- phites will prove an admirable remedy to relieve irritation of the lungs with atony, checking cough, and giving increased respira- tory freedom. At the same time it improves digestion, blood- making and nutrition. The hypophosphite of lime is one of the most certain remedies I have ever employed in the early stages of pulmonary tuberculosis. REMEDIES WHICH INFLUENCE THE DIGESTIVE APPARATUS. It cannot be too often impressed upon the physican, that a good condition of the digestive apparatus is of first importance in the treatment e)f any form of disease. If stomach and bowels are in fair condition we are careful not to disturb them. If there is anything wrong with them, the first object of treatment is to right this wrong. That system of medicine which irritates the stomach and keeps it in a state of unrest is intrinsically bad, increasing the suffering of the sick, prolonging disease, and greatly increasing the mortality. That system of medicine which disturbs the bowels, causing irritation or atony, wrongs the sick, intensifies suffering, and increases the death rate. If any one will call up his past experience in this direction he will realize the truth of these statements. How have you felt when suffering from nausea and vomiting, or even from gastric irritation short of this? Did you find it conducive to eomfeu't, to rest, te> appetite, digestion and normal functional activity? How would you like a teaspoonful of Lobelia or Sanguinaria before each meal—as a steady diet? How have you felt when suffering from a good old fashioned diarrhoea of six to ten evacuations a day? Is this conducive to comfort, to rest, to appetite, to normal functional activity? When you are on the outside of two or three grains of Podophyllin, one or two drachms of compound powder of Jalap, or a teaspoonful e>f Cascara, was it comfort- ing to the inner man, and did it give strength to the legs and ability to work? If a well man does not take kindly to these 70 DISEASES OF CHILDREN. sensations, and finds that they impair his life, and all his func- tional activities, what must it be with the sick man, woman or child? These are questions which one should put to himself, and then see that they are answered. If we think of the function and relations of this apparatus we can see additional reasons for the rule I have named. It is the inlet for all the fluid and the foods required by the body, and these are required for sustaining the life. In the olden time it was thought that the sick person required no nourishment, but we now know that the sick may be starved, and are fre- quently starved to death. A certain digestive power is necessary, even though we are careful to furnish food that requires but little digestion, and this requires a reasonably good condition of stomach and intestinal canal. If one only thinks of the administration and absorption of medicines he will see the necessity of the rule. Unless the stom- ach is in fair condition medicines are not kindly received and ab- sorbed. The right remedy may be selected, which, if it gained entrance to the blood, would do that which is needed for the cure ; it is gi*ven, but wholly fails because absorption can not take place. The sympathies of the gastro-intestinal canal are very numer- ous and very sensitive, indeed it seems to be the center of morbid sympathies. If a distant part is involved in disease, the stomach speedily suffers; if the body at large is diseased, the stomach suf- fers. It is abundantly supplied with ganglionic nerves, and the solar plexus, the center of this system, lies immediately behind it, and is almost directly influenced from it. It is thus related to the circulatory, respiratory, and excretory apparatus. emetics. The act of emesis seems natural to the nursing child, relieving the stomach of repletion and nourishment that fails to digest. This would,point out the first indication for emesis, to relieve the stomach of food that can not be digested, or that is undergoing decomposition. For this purpose there is nothing better than warm water £iven freely, and its action in some cases of emergency assisted by tick- ling the fauces with the finger. A solution of common salt is also very good in such case's, and leaves no bad influence. The second indication for the use of an emetic is, when there are morbid accumulations in the stomach, from undigested and INFANTILE THERAPEUTICS. 71 decomposing food, or from an increased secretion of gastric mu- cus. It is met with occasionally in the first stages of severe dis- ease and is an unfavorable complication, for such condition of the stomach precludes the taking and digesting of food, and the proper appropriation of remedies. Frequently, in such cases, the medi- cines given will be ejected from the stomach two or three times a day, or may not be tolerated at all. The third indication for the use of an emetic is, for the removal of material from the respiratory organs. This is generally mucus, occasionally mucus and pusr. The emetic is only employed in this case, when we have such evidence of the loosening of the mucus as will lead us to believe that it may be removed in this way. Emetics are employed in nauseant doses to aid in soften- ing, diminishing the plasticity, and loosening such accumulations. The fourth indication for the use of an emetic is, to rouse the nervous system from severe depression, and restore a uniform cir- culation of blood. For this purpose it is employed in scarlatina maligna, in the severer forms of rubeola and variola, and occa- sionally in other diseases. Ipecacuanha. I administer ipecac to fulfill the second indica- tion of an emetic. It is given in the form of powder, mixed with warm water, and assisted in its action by warm water or some warm tea. The dose for a child two years old, will be from three to five grains; for an infant, half to one grain. Acetous Tincture of Lobelia and Saguinaria.—1^ Lo- belia, Sanguinaria, Ictodes, aa., gij.; distilled vinegar, Oij.; alcohol, gij,; make Oij. of tincture by percolation; dose from five to thirty drops. To fulfill the third and fourth indications for an emetic, I pre- fer this preparation to any other that I have employed. It is repeated every five, ten, or fifteen minutes, until thorough emesis is produced, and its action is aided by warm drinks. After the use of any emetic, the child should have warm drinks for some hours, but it is not necessary that they should be ob- jectionable to the taste; a thin corn meal gruel or common tea, or hot water, does very well. 72 DISEASES OF CHILDREN. CATHARTICS. The employment of cathartic medicines for every ailment, and in all conditions, was not only an absurd, but a very injurious practice. It arose from a misconception of the use of the intes- tinal canal. Instead of being a cloaca or drain fen- the effete materials of the body, it performs the most important part of the process of digestion ; as an excretory organ its function is less than the skin, and two-thirds less than the kidneys. Cathartics act upon the entire digestive tract, and in a manner subversive of natural pre>cesses. As the function of digestion is so important to health, furnishing the material for the nutrition of all structures, we should be very careful how we interrupt it anel set up unnatural actions. The frequent use of cathartics depends somewhat on the em- pirical benefit that follows their use in slight diseases. A person has a headache, a cathartic is taken, and the next day he is well; or he has an indigestion, and a cathartic preventing his eating for the time being, makes him feel better in a day or two; or he has caught cold, and an active cathartic, acting as a derivative, gives relief. But in these cases the influence is more apparent than real, time and abstinence from food being the important requirements. It may be asserted that a person in the habitual use of cathar- tics can not enjoy good health, and that the occasional use is injurious in the same proportion. I hold that they should never be employed unless there is a special indication for their use, which indication we will now consider. The first indication for the use of a cathartic is, to remove accumulations from the bowels that are proving irritant. These are more frequently of undigested food with the natural secre- tions. The symptoms are, an uneasiness of the child, manifestly from the abdomen ; impaired or arrested appetite, and digestion • a uniformly coated tongue, usually with a yellowish shade • and occasionally a peculiar puffy, expressionless appearance of the face. A cathartic is never indicated when the child is well, though the bowels have not moved for days. The second indication for the use of a cathartic is, to produce revulsion or counter-irritation in case of serious disease of im- portant organs. Thus, in the past, it was the principal means of reaching a determination of blood to the brain, inflammation of INFANTILE THERAPEUTICS. 73 the brain, congestion of the brain, and occasionally inflammation of other parts. Our means of cure, and especially of reaching these diseases, have so increased that this use of cathartics will be rare. The third indication for the use of a cathartic is, to promote the absorption of dropsical effusions. Even this use is becoming obsolete by the discovery of specific medicines for this purpose, without disturbance of the digestive tract. Cathartic medicines are employed in small doses to stimulate the digestive tract, and increase its innervation and circulation. They increase the secretion of the digestive fluids and thus im- prove digestion, anel at the same time increase the activity of its excretory glandulae. For such purpose the remedy is thoroughly triturated with sugar, or sugar of milk, and the dose is below that which woulel prove laxative. Used in this way, some of this class furnish the most certain and efficient alteratives. Amygdalus. Specific Indications.—There is irritation of stomach with nausea, vomiting, sense of heat and burning. The tongue is elongated and pointed, with reddened tip and edges. Dose.—We prefer an infusion of the fresh bark of the green twigs in half teaspoonful doses, but the tincture may be used in the proportion of gtt. x. to gtt. xx., water giv., (a little ice may be added), in doses of half to one teaspoonful every fifteen to thirty minutes. The peach-tree bark will be found an excellent remedy to relieve irritation and determination of blood, with its attendant nausea and vomiting. As it relieves gastric irritation it will be found to give rest to the nervous system, and a better circulation of blood. Rheum. Specific Indications.—There is nausea, vomiting, un- easy sensation in stomach, irregularity of bowels, diarrhoea, with light colored discharges. Dose.— fy Tinct. Rheum gtt. v. to gtt. xx., water giv ; half to one teaspoonful every half hour or hour, or compound powder of Rhubarb gj., boiling water giv.; make an infusion and strain, and give in half teaspoonful to teaspoonful doses. Homoeopathic Indications (3d to 6th decimal) Sour smelling diarrhoea in children. Colicky pains before or during stool. Difficult dentition. Longing for various things, but the first morsel satisfies.—Ehrmann. 74 DISEASES OF CHILDREN. Rhubarb is an old and favorite remedy with our school. The old compound powder in infusion was used to relieve irritation of the stomach, check nausea and vomiting, and cure diarrhoea. For the first purpose it was used in small doses frequently re- peated; for the second it was continued in teaspoonful doses until the discharges had the color of the medicine, then less frequently. Diarrhoea from cold was readily relieved by it, and it would cure the simpler cases of cholera infantum or summer complaint. The tincture will sometimes be found an excellent stomachic, improv- ing digestion as well as relieving irritation. Lobelia. In very minute doses Lobelia allays irritation of the stomach and checks nausea and vomiting. When the tongue is broad and full—atonic—the remedy will sometimes (minute doses) act as a tonic and improve digestion. Its action as an emetic has been referred to. Ipecacuanha. Specific Indications.—There is irritation e>f stomach, small or large intestine, with determination of blood. Nausea, vomiting, diarrhoea, dysentery; the discharges in each case being somewhat violent and painful. Violent and expulsive cough, with sense of irritation and burning; mucus or muco-pur- ulent expectoration ; globular sputa, rusty; hemorrhage. Dose.—Ty Tinct. Ipecac gtt. v. to gtt. x., water giv.; a tea- spoonful every hour. Homoeopathic Indications (3d to 6th decimal.) Constant sensa- tion of nausea, with vomiting of mucus, bile or blood; the nau- sea continues after vomiting. Colic and diarrhoea, stools look like yeast, smelling sour. Suffocative attacks of breathing, res- piration oppressed, anxious, quick ; cough, with rattling of mucus in the bronchial tubes. Intermittent fever, nausea and vomiting predominate; chill with thirst, followed by fever; cases in which quinine has failed.—Ehrmann. Ipecac is a favorite remedy in disease of the stomach and in- testinal canal. It relieves irritation and quiets nausea checks vomiting, and improves the functional activity of the stomach. It is a very certain remedy in diarrhoea from irritation, with de- termination of blood, or muco-enteritis, from the simplest form to the severer cases of cholera infantum. It is also a prominent remedy in dysentery, quieting irritation, relieving pain and lessening the frequency of the discharges. In all of these cases we generally use it in combination with Aconite. INFANTILE THERAPEUTICS. 75 Euphorbia IIypericifolia. Specific Indications.—Diarrhoea, sense of heat in stomach and abdomen ; abdomen is hot to the hand, some tenesmus with discharges, which are at times acrid. Bronchitis, with thin, acrid secretion. Dose.—fy Tinct. Euphorbia gtt. v. to gtt. xx.; water giv.; a teaspoonful every one to three hours. The Euphorbia is a most excellent remedy in the treatment of cholera infantum and in diarrhoea, filling a similar place to Ipecac. In some years it will be found preferable to this remedy, in other years the Ipecac will prove the best. Colocynth. Specific Indications.—Wandering pains in the abdeunen, seemingly in the course and from contraction of the intestine; the intestines are felt to change their position; noise from the movement of the intestinal contents; tormina and tenes- mus ; dragging from the umbilicus ; frequent desire to stool from pressure in the rectum, with burning sensations. Dose.— R; Tinct. Colocynth gtt. ij. to gtt. v. water giv.; a tea- spoonful every one to three hours. Homoeopathic Indications, (3d to 6th decimal).—Violent pain in the abdomen, causing the patient to bend double; diarrhoea, worse after eating or drinking, stools frothy, smelling acid or putrid; dysentery, discharges of mucus and blood with tenesmus, morbus coxalgia; when there is a sensasion as of being encircled with an iron band; urine viscid; general shortening of the ten- dons.—Ehrmann. With the symptoms as above named, Colocynth is an excellent remedy for diarrhoea and dysentery, and for colic. It relieves pain, checks the discharges, and promotes normal functional ac- tivity. In infantile colic, with free, acrid discharges, it will be found an admirable remedy if the dose is very small, gtt. j. to water giv., or a Homoeopathic dilution is used. Hamamelis. This remedy has been fully studied, and we notice it here as a remedy which gives tone to stomach and intes- tinal canal, allaying irritation and promoting functional activity. It may be used when the child persistently throws up its fe>od mixeel with mucus; in diarrhoea with large, light colored dis- charges, and when there is prolapsus ani. If the abdomen is full and doughy, the remedy (distillate or Pond's Extract) may be used as a local application, and if there is relaxation of the 76 DISEASES OF CHILDREN. perineum with prolapse of the bowel, it may be locally applied to the parts. Chionathus. Specific Indications.—Fullness in right hypo- chondrium; pain in hypochondria, extending to umbilicus; pain in right shoulder; yellow (jaundice) coloration of eyes and skin; colic with excessively green discharges from the bowels; high colored urine, coloring the clothing yellow. Dose.—The dose will vary from gtt. v. in water giv., a tea- spoonful every one or two hours, to gtt. j. to gtt. v. at a dose. The Chionanthus will be found a most valuable remedy in the treatment of jaundice, and those painful affections of the bowels, associated with irregular action of the liver. When the chilel suffers with infantile dyspepsia, and there is fullness in the region of the liver, it may also be employed. Uvedalia. Specific Indications.—Enlargement of the spleen ; full abdomen, doughy; enlargement of the liver (liver-grown); enlargement of any part, the circulation being feeble and the tissues atonic. Dose.—For children I only recommend it as a local application, the affected part being thoroughly rubbed with the ointment of Uvedalia, or with one part of the tincture to two or three parts of cod-liver or sweet oil. With the indications named there is no remedy equal to it. I have seen the enlarged spleen in the malarial fevers of infancy as early as the third month, and it will be found more frequently than physicians suspect. With this disease of the spleen the patient can not easily be cured of the fever, or if the fever were stopped he would still suffer from impaired blood making (lukae- mia). It is also valuable in chronic inflammations of any part, the circulation being feeble, and tissues atonic. Nux. This remedy, fully described in the first class, has a direct action upon the gastro-intestinal canal. It is indicated bv evidences of atony, and an enfeebled circulation. Nausea and vomiting with a pallid, expressionless face, is speedly relieved by minute doses, as gtt. j. to water giv. We use it in the cure of diarrhoea, when the discharges are large, the abdomen full and relaxed, and when there is pain simulating colic. It is one of our best remedies for infantile colic, if there are infantile therapeutics. 77 no evidences of irritation and determination of blood. The pulse is feeble, the extremities cool, and abdomen full. It is an excellent stomachic, and if an indigestion depends upon an enfeebled innervation and circulation, the patient will be benefited by it. A sallow, expressionless face, yellowness about the mouth, slight yellowness of the eyes, and clay-colored dis- charges are indications for Nux. In cholera infantum we say that Nux is the remedy when there is atony of the bowels, with feeble circulation. Aconite where there is irritation with determination of blood ; Ipecac or Eu- phorbia being associated with either. Ciielidonium. Specific Indications.—Fullness in hypochon- drium, tongue much enlarged and somewhat pale; mucous mem- branes full and pale; skin full and sallow, sometimes greenish; tumid abdomen; light colored feces; no abdominal pain ; urine pale, but cloudy and of high specific gravity. Dose.—Py Tinct. Ciielidonium gtt. v. to gtt. xv., water giv., a teaspoonful every two or three hours. Homoeopathic Indications, (3d to 6th decimal).—A fixed pain under the inner and lower angle of the right shoulder blade, in chest or liver affections ; orbital neuralgia of the right side, with profuse lachrymation ; great sense e>f tightness around the neck above the larynx, hindering deglutition ; constipation, stools like sheep's dung; gallstones with jaundiced complexion; reddish or greenish urine. Podophyllin. Specific Indications.—The tongue is full, face full, abdomen full, veins full; enfeebled innervation through the sympathetic; dull pain, dull headache, dizziness. Dose.—In diseases of children I prefer a second decimal tritu- ration, which may be given in de>ses of from one-eighth of a grain to one grain. In older children granules containing 1-40 of a grain of Phodophyllin with 1-8 grain of Hydrastia will se>me- times prove beneficial as a stimulant to the stomach and intestine. Homoeopathic Indications (3d to 6th decimal.) Depression of spirits. Giddiness, with sensation of fullness over the eyes. Difficult dentition, very offensive stools, moaning eluring sleep, half closeel eyes and rolling the head from side to siele. Diarrhoea, especially in the morning or soon after eating. Prolapsus ani. Prolapsus uteri. Pain in the ovarian region. Suppression of the menses, with bearing down sensation, better when lying down. 78 diseases of children. Pain in the sacrum, with uterine troubles. Whooping cough, with constipation and loss of appetite.—Ehrmann. We employ Podophyllin and Podophyllum as a stimulant to the sympathetic nervous system, improving innervation to all parts supplied with ganglionic nerves. The indications for its use in wrongs of the digestive apparatus are those of atony—full expres- sionless tongue, full abdomen, impaired functional activity. In " gastric and intestinal dyspepsia, with these evidences of atony, a trituration of Podophyllin will be found an excellent remedy. The liver may be stimulated by it, the portal circulation improved, and the spleen relieved of its overflow of blood. We employ it as a remedy for diarrhoea when the abdomen is full anel doughy, the discharges light in color, mucous, or contain- ing undigested food. Of course the dose is small, much smaller than most physicians use. Some cases of cholera infantum are cured with a trituration of Podophyllin, when the ordinary treat- ment has wholly failed. Hydrastis. Specific Indications.—The mucous membranes are flushed ; papillse of tongue prominent and red; uneasiness in stomach; loss of appetite; impaired digestion.; mucoid matter with stools; circulation to surface and extremities feeble. Sore mouth, with increased mucus secretion, thick and tenacious saliva ; sore throat, with muco-purulent secretion ; sore eyes, with muco- purulent secretion. Dose.—I prefer for use the yellow alkaloid Hydrastis or Ber- berin, which is very soluble; one grain to four ounces, make a very good tonic, and is about the strength we would use as a wash for the mouth and throat or as a collyrium. Homoeopathic Indications (3d to 6th decimal.)—Sensation of sinking at the epigastrium with palpitation of the heart; loss of appetite and fainting paroxysms; yellowish leucorrhoea of a very tenacious character, sometimes offensive; malignant and cancer- ous forms of ulceration ; cancer of the breast; constipation with gastric disturbance, flatulence; small-pox when the pustules are dark colored and there is great prostration, the face is very red and facial oedema quite marked; throat very sore.—Ehrmann. Dioscorea. Specific Indications.—Abdominal pain, shifting, paroxysmal, relieved by pressure or by supporting the abdomen and keeping the patient still. Skin soft, and feels as if perspira- tion were about to start; extremities cold; uneasy sensation in INFANTILE therapeutics. 79 lower part of the chest with sense of constriction in epigastrium. Dose.—Rj Tinct. Dioscorea gtt. v. to gtt. x., water giv.; a tea- spoonful every fifteen minutes to an hour. Dioscorea is an excellent remedy in infantile colic, if it pre- sents the symptoms named, but it will not do to use it when Nux or Colocynth are indicated. It is also an excellent diaphoretic, but when used for this purpose I administer it with hot water. Children will frequently show the evidences of cold, with tendency to cough, and the respiratory movement will be observed to be short, as if there were some obstruction in the lower part of the lungs. The Dioscorea is a good remedy in this case. Apocynum. This remedy has been studied in the second class, as it influences the circulation. We emph)y it here as a stimu- lant to the entire gastro-intestinal tract, the indications being a full, tense abdomen, the skin glistening, with oedema of some part. In very small doses it increases the activity of the bowels, and overcomes constipation, and if the dose is a little too large will cause diarrhoea. It will be found an admirable remedy in acute hydrocephalus, as it is in the chronic form of the disease. Irritation of the nervous system, with prominent eyes, fullness of the fontanells, or opening of the sutures. A very common indi- cation for Apocynum is oedema of the eyelids, or that wrinkled appearance that the eyelids present when they have been swollen. Chamomilla. Specific Indications.—Infantile dyspepsia with irregularity of the bowels; diarrhoea with flatulence and colic, discharges contain curdled milk or other undigested food; the person is irritable and restless and the surface alternately flushed and pale. Dose.—R; Tinct. Chamomilla gtt. v., water giv.; a teaspoonful every one to three hours. Homoeopathic Indications, (3d to 6th decimal).—Great sensi- bility to pain, making the patient cross and uncivil; children crying and fretting, must be carried about in order to be appeased ; diarrhoea which smells like rotten eggs, and looks like chopped eggs and greens, especially during dentition ; one reel cheek while the other is pale, with great irritability and thirst; flatulent colic of infants.—Erhmann. 80 DISEASES of children. Iris. Specific Indications.—Fullness of thyroid gland, enlarge- ment of lymphatic glands, fullness e>f spleen, grayish or coppery coloration of skin, chylous discharges from the bowels. Dose.—Ify Tinct. Iris gtt. v. to gtt. x., water giv. ; a teaspoon- ful every one to three hours. Homoeopathic Indications, (3d to 6th decimal).—Sick headache, with vomiting of mucus, tasting sweet; fullness and heaviness of the head, head and face cold ; colic relieved by bending for- ward; brown and very offensive diarrhoea, with cutting pains, nausea and vomiting, einmission of foetid flatus.—Ehrmann. Leptandria. Specific Indications.—Fullness of abdomen, doughy sensation to touch ; tongue full, pallid, and covereel with pasty fur; stools papescent and light colored; tawny, dirty skin, dirty eyes. Dose.—Leptandria triturated one to ten may be given in half grain doses, or the tincture may be used with glycerine or syrup so that the patient will get from one-fourth to five drops at a dose. Homoeopathic Indications, (3d to 6th decimal).—Black fluid stools, great urging, with difficulty in retaining the stool ; cutting pains about the umbilicus; stools like tar; chronic diarrhoea, worse in the afternoon.—Ehrmann. Sulphate of Manganese. Specific Indications.— A pale, leaden tongue, dirty, with pendulous abdomen and sluggish bowels; jaundice with enlarged liver, fullness and weight in right hypogastrium, dropsy. Dose.—For administration to children I prefer a second deci- mal trituration, of which one-half to one grain may be given every three hours. Malt. Specific Indications.—The digestion of calorifacient fe>od is imperfect, nutrition is impaired, and there is a tendency to scrofulous or tubercular deposits. Dose.—Any of the good extracts of malt may be used in doses of one-fourth to one teaspoonful three times a dav. Or instead of this an infusion of malt may be prepared and given to the child with its fe>od, or immediately after eating. It is believed that malt contains a similar ferment to the saliva (ptyalin), and to a less extent to the pancreatic fluid (pancreatin). The first has an especial influence upon starch, changing it into grape sugar; the second will peptonize proteids, emulsifv fats anel infantile therapeutics. 81 convert starch into sugar. AVhen these processes are imperfect and children suffer frenn impaired nutrition, anel cacoplastic or aplastic deposits, malt has been found to give good results. Pepsin. Specific Indications.—Gastric digestion is impaired, and nutrition is imperfect; there are eructations of food and gas, chylous or lienteric diarrhoea, abdomen full, urine cloudy. Dose.—Of a good pepsin one-fourth to one half grain may be given with or after the taking of food. Oxide of Zinc. Specific Indications —The tongue has a pasty coat, breath bad, eructations of food, waterbrash, gastro- dynia; secretions of mouth become so acrid that they excoriate the mucous membrane and lips, and produce soreness of the nipple. Dose.—It may be used in pill form (granules), the dose being one-tenth to one-fourth grain, or it may be employed in the second decimal trituration in eloses of euie grain. Homoeopathic Indications (3d to 6th decimal.)—AVeakness of memory. Indisposed to converse. Great sensitiveness to noise. Hydrocephalus. Sen-cness of the eyes, lids and inner angle of the eyes, great itching. Paralysis of the upper eyelid. Otalgia, discharge of fetid pus from the ear. Great burning in stomach after taking sweet things. Great greediness when eating, can't eat fast enough. Nausea and vomiting. Metallic taste in the mouth. Patient can't keep still, must be in motion all the time. Varicose veins which give rise to fidgetiness of the limbs. Puerperal convulsions. Scarlet fever when there is retrocession of the eruption. Child unconscious and motionless. Involun- tary jerking and twitching of the muscles. Grinding of the teeth. Screaming spells. Occiput very hot and forehead covered with cold perspiration. Pulse thread-like and difficult to count. —Ehrmann. Santonine. Specific Indications.—Fullness of the upper lip, white line around the mouth, picking at the nose, foul tongue, fetid breath, full pendulous abdr»men, tendency to retention of urine. Dose.— As a remedy for worms I usually combine it with Podophyllin as in the following—It Podophyllin gr. j., Santo- nine gr. x., Sugar, or Sugar of Milk oj.; triturate thoroughly anel make twenty powders, of which one may be given night and 6 82 DISEASES OF CHILDREN. morning. In retention of urine I have it triturated with sugar, so that the child may have a dose of one-eighth to one half grain every one to three hours. Santonine is one of the best remedies we have to expel the ascaris lumbricoides, and to so influence the mucous membrane that the intestine will not be a habitation for these vermin. The combination Avith Podophyllin is very good when there is atony with increased secretion of mucus, but if there is irritation of the intestine, the remedy may be triturated Avith sugar and a minute portion of Ipecac. In retention of urine in childhood it is par excellence the remedy, and I have not known it to fail in an experience of twenty years. It is not a question of how or Avhy it influences the bladder, but the fact that Avhen there is retention of urine from one to three doses of Santonine will cause its passage. Aloes. Specific Indications.—There is atony of large intestine and rectum, mucoid discharges, prolapsus ani, pruritus ani, ascaris vermicularis. Dose.—The remedy is a very nauseous one, and it is difficult to use it on this account. A second decimal trituration may be given in doses of one grain, or even a trituration of one to ten may sometimes be used. To remove the ascaris ATermicularis, and break up the conditions under Avhich it propagates itself, I have found that the following prescription does Avell: R> Tinct. Aloes, Comp. Tinct. Cardamom, aa. gss., Syrup gj. ; dose, one- half to one teaspoonful until it acts upon the bowels. Homoeopathic Indications (3d to 6th decimal.)—Sensation of Aveight or heaviness in the rectum;'morning diarrhoea very urgent, must go at once; rumbling and rolling in the bowels be- fore stool; hemorrhoids protruding, feeling hot and sore- when urinating sensation as though something had passed from the bowels; stools consisting of jelly-like mucus. REMEDIES THAT INFLUENCE THE URINARY APPARATUS. AATe find in practice that, in a majority of acute diseases the function of the kidneys will be re-established so soomas the cir- culation is controlled. Hence, in the common diseases of ohild- lmod diuretics are not required. It is principally in the malarial fevers, and in zymotic diseases that they will be demanded. In INFANTILE THERAPEUTICS. 83 chronic disease, with deficient Avaste and excretion, they become our most important remedies. Here, as in the adult, we recognize the two actions, hydragogue anel depurant. In the first, the water of the urine is increased ; in the second, the solid constituents are increased. The first may be used to lessen the volume of the circulating fluid, to remove irritations of the urinary passages by diluting the urine, and to promote the absorption and removal of dropsical deposits. The second, increasing the solids of the urine, are used to depurate the blood of worn-out and imperfectly-formed material. They also stimulate the processes of retrograde metamorphosis, and thus facilitate the breaking down and removal of tissue, and indi- rectly its renewal. AVe might give a long list of remedies influencing the urinary apparatus, but a few Avill ser\re our purpose, as in diseases of children especially, the kidneys will do their work if the general conditions are right. The agents we will study are:— Sweet Spirits of Nitre, Mentha Viridis, Cucurbita Citrullus, Acetate of Potash, Gelseminum, Rhus Aromatica, Eupatorium Pur., Santonine, Agrimonia, Hydrangea, Apis, Belladonna, Benzoate of Lithia, Local applications to the Loins. Saveet Spirits of Nitre. I name this remedy first, because it has been employed so extensively, and Avith good advantage, in diseases of childhood. In this case it is not only diuretic, but, to a slight extent, sedative—lessening the force and frequency of the pulse. It is only in the simpler forms of disease that I Avould recommend it. To two ounces of water, in a glass, add a tea- spoonful of spirits of nitre, keep covered, and give a teaspoonful' every two hours. This is the dose for a child from one to two- years of age. Mentha Viridis. Though not usually regarded as of much importance by the profession, and as having but feeble diuretic properties, I think in diseases of children it will be feiund one of the most certain of remedies. It has this advantage, that, pre- pared in strong infusion and sweetened, it is quite palatable, and it may be given freely without danger. I give it alone and in combination. With sweet spirits of nitre a verv powerful hydragogue action may be obtained. If there is irritation of the urinary apparatus, I generally add tincture of 84 diseases of children. Gelseminum in small doses. If the pulse is excited I give Ve- ratrum at the same time. Or, if there is congestion with ten- dency to coma, Belladonna. Cucurbita Citrullus. An infusion of Avatermelon seeds is a very mild unirritating diuretic in diseases of children. The only difficulty we find in using it is, that children Avill not drink unless they are thirsty, and in sickness they are very particular what they drink, and may not like Avatermelon-seed tea as a sub- stitute for water. Acetate of Potash. Specific Indications.—The tongue is full, pallid, slightly leaden, and coated with a pasty fur; the abdomen is full and doughy, and the skin dirty. Dose.—!R< Acetate of Potash 5j., water giv.; a teaspoonful every two or three hours, with as much fluid as the patient can be persuaded to take. Of the class renal depurants, Acetate of Potash is the most effi- cient. It is employed to increase the solids of the urine, and remove the waste from the blood. When given in large doses, and for some time, it breaks down feeble tissues, and thus hastens the removal of worn-out material. But having such action, it may be carried too far, to the weakening and breaking down of sound tissue, or to the remoA'al of material faster than it can be replaced. It is a good remedy in its place, but used to excess it is injurious. In many cases it may be added to the child's drink, so that the necessary quantity will be taken in the course of the day, Avithout its knowledge. For a child two years of age the medium quan- tity will be half a drachm, each twenty-four hours. Citrate of potash, bitartrate of potash, nitrate of potash, and acetate of soda may be used for the same purposes. Santonine. We think of Santonine as a vermifuge only, yet it has other desirable properties. One of them is. its influence oA'er the bladder in retention of urine. In some diseases there is sometimes a tendency to retention Avhich ordinary remedies Avill not reach, and Avhich at last proves fatal. Santonine thor- oughly triturated with sugar, in doses of from half to one grain every two hours, affords very certain relief. It is also very effec- tual in relieving burning, scalding, tenesmus, and other unpleas- ant sensations of the urinary passages. infantile therapeutics. 85 Eupatorium. Specific Indications.—There is a sensation of weight and dragging iu the loins, retraction of testicles, frequent desire to urinate, scanty secretion of urine. Dose.—R> Tinct. Eupatorium gtt. x. water giv.; a teaspoonful every one or two hours. When there is a continued scanty secretion of urine, though the general wrongs have been looked after, we may think of the Eupatorium. The indications as given abo\re, will be found a good guiele to its administration. Gelseminum. Gelseminum has been studied in our first class, anel we notice it here as a remedy directly influencing the kidneys, relieving irritation and determination of blood. The indications fe>r it are, sharp pains in the loins and back, frequent desire to pass urine, which is passed in very small quantities Avith tenesmus. It is ne>t only a remedy for irritation and determination of blood to the kidneys, but for irritation of any part of the urinary passages as well. In cystitis it is a favorite remedy, as it is in irritable (spasmodic) stricture of the urethra. Eryngium. Specific Indications.—Frequent desire to pass water, with vesical tenesmus, contraction of abdominal muscles, drawing up of the thighs, scanty urine, acrid, irritatiug the ex- ternal parts. Dose.—R; Tinct. Eryngium gtt. v., water giv.; a teaspoonful every one to three hours. Eryngium is an admirable remedy to relieve irritation of the bladder, and I have no doubt that it exerts quite as strong an influence upon the pelvis of the kidneys and ureters. It alse> increases the secretion of urine, which is less acrid and irritant, Belladonna. This remedy has been fully studied, and we notice it here as a remedy for congestion or enfeebled circulation of the kidneys, and for diabetes and incontinence of urine. In cases where the patient complains of fullness, AA'eight and drag- ging in the loins we prescribe Belladonna. When the urinary secretion is too free, the urine of low specific gravity, the admin- istration of Belladonna internally, or the application of a Bella- donna plaster to the loins is good treatment. In incontinence of urine this remedy has given most excellent results, especially in those cases Avhere there was inability to hold the urine during the day, and a dribbling away which soiled the clothing. 86 DISEASES OF CHILDREN. Rhus Aromatica. This agent is highly recommended fe>r incentinence of urine, especially for nocturnal incontinence. It is also used in irritable bladder; in chronic cystitis and urethritis; in phosphuria, and when there are mucoid discharges in the urine. Dose.—Py Tinct. Rhus Aromatica gtt. v. to 5j-> Avater gij.; a teaspoonful every two or three hours. Agrimonia. Specific Indications.—Renal colic, pains ex- tending from the hypochondria to the loins, and thence down to the bladder. Irritable kidneys; irritation of kidneys or the urinary passages, with cough; cough attended Avith expulsion of urine. Dose.—R; Tinct. Agrimonia gtt. v. to gtt xxx., water giv. ; a teaspoonful every one to three hours. Hydrangea. Specific Indications.—Irritable bladder and urinary passages, urine passed Avith difficulty and with tenesmus, blood in the urine, strangury, irritation of urinary passages Avith cough. Dose.—R; Tinct. Hydrangea gtt. v. to gtt. x., water giv.; a teaspoonful every one to three hours. Apis. Specific Indications.—Itching of the genitals; itchino along the urethra ; burning in the bladder; itching of the anus ; itching and burning of the skin ; eyes itch and burn; child wants to rub them frequently. Dose.—R Tinct. Apis gtt. ij. to gtt v., water giv.; a tea- spoonful every hour te> three hours. Homoeopathic Indications (3d to 6th decimal).—Burning and stinging pains with scanty secretion of urine; breathing labored with fever without thirst; dropsy without thirst, and waxy ap- pearance of the skin ; ©edematous swelling of the face, especially about the eyes; hydrocephalus, Avith sudden shrill cries; boring of the head in the pillow, squinting, grinding of the teeth, urine scanty, twitching on one side while the other is paralyzed.__ Ehrmann. AVith the indications as aboA-e named the Apis will be found an admirable remedy. I have seen it start a free secretion of urine in a few hours, Avhen it had been nearly arrested. It relieves irritation of the nerve centers, gives rest, improves the circula- tion, and especially removes hyperaesthesia of the cutaneous nerves. INFANTILE THERAPEUTICS. 87 Benzoate of Lithia. Specific Indications.—There is diffi- cult urination, discharge of mucus, muco-pus or phosphates with the urine; the skin is doughy or waxy ; the tongue dirty; the breath fetid, and general evidence of imperfect waste and nutrition. Dose.—It may be given to a child two years old to the amount of one grain each day in the water the patient takes. Homoeopathic Indications (3d to 6th decimal).—Urine scanty, of dark brown color, and strong urinous odor; nocturnal enuresis; rheumatism, Avith strong smelling urine; hypochondriasis, sore throat and diarrhoea, with the above characteristic urine.— Ehrmann. REMEDIES THAT INFLUENCE THE SKIN. It is hardly necessary to call attention to the importance of a healthy skin, as associated with good health, and to its impairment as a frequent cause and constituent of disease. This organ not only removes a large amount of nitrogenized Avaste, but it also regulates the temperature, and assists in the respiratory function. If its function as a regulator of the temperature (safety valve) is impaired, we will have a Avrong of this condition of life which Avill work a wrong of every function of life. If it fails to do its Avork of excretion, the blood must suffer from the retained ma- terial, unless the kidneys and bowels do vicarious work. Impair- ment of the skin thus imposes additional labor upon the lungs. In studying the pathology and therapeutics of the skin Ave must not forget its intimate relationship with mucous membranes. The skin and mucous membrane may be regarded as one piece— folded in, forming the internal lining or envelope, covering the body as an external envelope. The sympathy between the two is so intimate that wrongs of the skin Avork Avrongs of mucous membrane, and Avrongs of mucous membrane Avork wrongs of skin. An impairment of the functions of the skin may Avork such wrong of mucous membrane as to imperil life. AVe see this illustrated in some of the simpler eruptions upon the skin. A child suffers from heat, or some of the simpler forms of erythema or urticaria, but as long as it is out freely upon the skin, the functions of the body are well performed. From some cause the eruption disappears (goes in), and at once the child is very sick, has bronchial irritation, croup, or intestinal irritation with diarrhoea. A cure in such cases will come from bringing Sedatives, Rhus, Stimulants, Apis, Inunctions, Senega, Nepeta, Sulphur, Serpentaria, Arsenic. 88 DISEASES OF CHILDREN. the eruption to the surface, prevention of disease will come by keeping the eruption on the emtside. The remedies we Avill stiidy in this connection are the following: Baths, Diluents, Asclepias, Saffron, Belladonna, Eupatorium, Sedatives. In proportion to the frequency of the pulse and the increase of temperature is the arrest of secretion. If, there- fore, there is a frequent pulse, the first step toAvard obtaining a normal action of the skin is, to bring it down to the normal standard. The arterial sedatives thus become the most import- ant diaphoretic means. With small and frequent pulse Aconite is our best diaphoretic ; with a full, frequent pulse it is Veratrum ; with an oppressed pulse Lobelia, etc. In a large number of cases of fever and inflammation, if proper means are used to lessen the frequency of the pulse and bring the temperature to a normal standard, secretion from the skin is established in proportion as these effects are obtained. If secretion does not start as the pulse comes down, very mild diaphoretic remedies will be sufficient to accomplish the purpose. With a frequent pulse and high temperature no diaphoretics Avill act. Stimulants. There are cases where, from a feeble general circulation, and an enfeebled skin, secretion can not go on. This Avill be known by the dull color, Avant of elasticity, coldness, and want of sensibility. In such cases anything that will stimulate the general circulation, and will stimulate the skin and its circu- lation, will improve functional activity. I have used in such cases something like the following, Avith good results: R Tinct. Lobelia 3], Comp. Tinct. Lavender 3iij., Syrup giss.; give in teaspoonful doses, mixed with hot water every hour. R Tinct. Ipecac gtt. x., Comp. Tinct. Cardamom gss., Syrup giss.; tea- spoonful every half hour or hour, with hot water. An infusion of ginger or of Asarum canadense may sometimes be given. Baths. We have already studied the use of baths as a means of rectifying wrongs of the temperature, but Ave can not learn too much about these means, and a little repetition will INFANTILE THERAPEUTICS. 89 not be injurious, and we uoav want to know how they influence secretion. The success of Eclectic practice has, I think, depended quite as much upon the skilled use of the bath, as upon the administra- tion of internal remedies, and from the days of Beach great stress has been put upon " bathing the sick." It came in at a time when Avater was thought to be injurious, whether applied to the surface or given as drink, for Avater and mercury Avere antagonistic elements, and mercury the sick must have. In simple opposition, therefore, if for no other reason, Ave washed our patients frequently, and gave them as much Avater as they could drink. The Alkaline Sponge Bath.—1' The alkaline bath," Avas the one most generally recommended and used, and this was a potash, not a soda bath. In early days it Avas made by adding Avooel- ashes to Avater (broke Avater) so as to render it slightly slippery ; now we use bicarbonate of potash. It has a very kindly influ- ence upon the skin, softening it, lessening the temperature, pro- moting a better flow of blood and increased secretion. In some cases soda may be substituted for the potash with advantage, but as a rule the old alkaline bath is the best. There are cases in which the skin is influenced better by simple soap and water. The Acid Sponge Bath.—AVhen the tongue and mucous mem- branes show a deep-red or dusky color, and the skin also shows dusky redness, an acid bath will sometimes be preferable. If the ordinary bath is used it seems to leave the skin drier and harsher than it was. If we now add a portion of vinegar to the Avater, it softens the skin, lessens the temperature, and aids secretion. Cold Wet-Sheet Pack.—In recent disease where the attack is acute and the patient strong, the cold wet pack may be used to advantage. The temperature is increased, the pulse frequent and strong, and the skin dry. The only objection to it is, the fear of the parents that some harm may follow, and the indisposi- tion of the child to have such liberties taken Avith it. Resolving on a cold wet pack, we have the little fellow stripped, a sheet of proper size Avrung out of cold water and wrapped around him, and then tuck him in his crib or bed, with plenty of covering. Half an hour to one hour is about the time we should allow him to be in it, when he may be thoroughly dried Avith rubbing, and haAre dry Avarm clothing put on. 90 DISEASES OF CHILDREN. Local packs may be used to any part which is suffering from increased heat and arrested secretion. The point we place stress upon is, that there shall be a vigorous circulation. It will not do to trust to the reaction to obtain a good circulation and temper- ature though sometimes the reaction from the cold is sufficient for this. Hot Wet-Sheet or Blanket Pack.—When the skin is feeble, its circulation impaired, and especially Avhen Ave Avant to bring an eruption upon the surface, Ave use the hot blanket pack. Some- times an internal congestion will demand speedy means of relief. In the eruptive fevers, if the eruption fails to make its appear- ance the patient becomes dull, sleepy or comatose, and the skin has a dull pallor or is dusky—here the hot pack is a good thing. In using this, a blanket is wrung out of hot Avater, and applied around the child, which is then warmly covered in its crib; in some cases mustard may be added to the water to make it more stimulant. As the cliild does not like the hot application any better than it does the cold, and will not bear it hot enough for benefit, Ave sometimes apply the hot blanket over a thin under- shirt and drawers ; it can then be very much hotter. Local hot packs are employed when parts are feeble, and have a sluggish circulation. The Hot Foot Bath.—Every person thinks that he or she knows all about the use of this simple means, but yet we find in practice that not one in ten can use it so as to benefit a child. The adult will have a full bucket of hot Avater, and the limbs covered ; the child will have one or two inches in a shalloAV basin, not very hot, and the limbs exposed up to the body. In the majority of cases the nurse dashes the water upon the child's legs Avith the hands, thus proelucing rapid evaporation, and of course refrigeration. Necessarily, the desired influence is not produced, and very frequently it has the contrary effect to that desired. So confident am I that the foot bath will be used in this way, that I never order it without giving specific directions, and many then misuse as above. Hot Sponge Baths. Sponging the surface with Avater as hot as it can be borne is sometimes a most admirable stimulant to the surface, and very much better than the hot bath. If the skin is very inactive, with a feeble circulation, I recommend the use of hot Avater with a sponge lightly and briskly applied, the patient being covered with a blanket. In the eruptive fevers, when there INFANTILE THERAPEUTICS. 91 is a tardy appearance of the eruption, no better means can be found than this; in some cases the eruption seeming to follow the hot sponge. In these cases I am in the habit of directing the nurse to apply the hot sponge to any part that suffers pain or uneasiness, or Avherever the eruption may not come freely to the surface A hot iron Avrapped in flannel and wetted Avith vinegar so as to raise a vapor is a still more acti\7e application, and one of the most powerful stimulants known. It is claimed that a current of electricity is thus generated, and we faradize the surface as well as stimulate it with heat. The Hot Bath.—A general hot bath may be given in any ves- sel large enough to hold the child. The Avater should have a temperature of 125 degrees at least, and should cover the entire body. The child should not remain too long in it, and Avhen removed should be Avrapped in a warm blanket until thoroughly dry. Common salt may be added to the water, when there is much debility, or a tendency to congestion. AVith care, such a hot bath may be used with advantage in the early stage of acute diseases. Inunctions.—There are cases Avhere fatty inunctions answer a better purpose than baths. The bath leaves the skin dry and harsh and inactive; the inunction leaves it soft and pliable, and in better condition for functional activity. Sometimes we use lard alone, or, if there is a tendency to aplastic deposits, cod-liver oil. AVhen there is periodicity, or when avc wish to get the action of quinine it is added to the lard. If we Avish the inunction stimulant, we add one of the essential oils in small quantity (they are very active Avhen combined Avith fatty matter). In scarlet fever Ave sometimes have the patient rubbed thor- oughly Avith a bacon-rind or piece of fat bacon. Or, Ave may order it from the drug store as follows:—R) Creasote gtt. xx., Common Salt oss., Lard gij. Ammonia added to the lard makes a very stimulant application, and I sometimes order it Avhen the skin is very feeble, or when it is necessary to bring an eruption to the surface, as—R; Bicarbonate of Ammonia or Ilydrochlorate of Ammonia oss., Lard gij. Mix. Diluents A certain amount of fluid is necessary to the proper performance of function, and I am satisfied that many 92 DISEASES OF CHILDREN. times the sick suffer severely from the want of it, either because the physician does not think it worth his while to loe>k after such small matters, or the condition of disease is such that it can not be introduced. Here Avas one of the evils of the old practice— they used remedies Avhich Avere incompatible Avith Avater, or Avhich kept the stomach in such condition that water could not be ab- sorbed by the stomach. Warm Drinks.— An infusion of catnip, sage, chamomile, ascle- pias, and many other simples, or even hot water, will prove diaphoretic, and is sometimes useful in slight ailments. The difficulty in their use is the repugnance the child has to anything unpleasant, and to the quantity necessary to be given to get a diaphoretic influence. If warm drinks can not be taken, or sometimes if they can, Ave think it better to administer cold. I make it a rule to ask if my little patient has expressed a desire for Avater, and advise that it be given frequently if the child has any thirst. Some- times Ave will find that the little one takes it eagerly, and follow- ing its use the irritation and restlessness subside, and it goes to sleep. Again, Ave will find that the frequent giving of cold water in moderate quantities lessens the temperature and the frequency of the pulse, and the child is better in every respect. In some cases the child may have lemonade to good ad\^antage, either hot or cold, as it will take it best. In others, Avhey answers a most excellent purpose, and is taken with pleasure. AVhen the temperature is high, and fluids can not be taken by mouth, I think it well, in some cases, to use it by enema. Four ounces of cold Avater throAvn up the rectum will lower the tem- perature of the entire body two or three degrees. If there is continued nausea a very small portion of common salt may be added to the fluid used in this Avay. Asclepias. Specific Indications.—The pulse is strong the patient has sharp pain in some part, inflammation of serous mem- branes, skin hot and dry but not constricted, urine scanty pain- ful cough. Dose.—R; Tinct. Asclepias gtt x., water giv.; a teaspoonful every hour. Asclepias may be taken as the type of a diaphoretic, acting kindly, and promoting that normal activity, " insensible perspira- tion." The skin softens, the temperature comes doAvn the pulse INFANTILE therapeutics. 93 is less frequent, and the nervous system is relieved. It is especi- ally a ge>od remedy in pleuritis or pleuro-pneumonia, and in rheumatism involving synovial membranes. Eupatorium Perf. The Boneset has a direct influence upon the skin, and may be employed to good advantage Avhen the pulse is full and strong, and the skin gives the sensation that perspiration is almost ready to break out. It may be employed alone or in combination Avith the sedatives. Crocus Sativus. Specific Indications.—The skin is dull, mottled and inactive, afterwards becomes exceedingly dry and harsh with irritation of mucous membranes. An eruption shows itself beneath the skin, or there has been a retrocession. Dose.—Saffron maybe used in infusion, or the tincture may be given Avith Avarm water. True saffron is one of the most certain, as it is one of the kindliest of diaphoretics, and when it can be obtained it should be employed, especially in the eruptive fevers. It will be found very much better than the old remedies, Avhich irritate the stomach and bowels. Nkpeta Cataria. Specific Indications.—The skin is dry and harsh, mucous membranes of the air passages irritable, urine scanty, more or less pain in abdomen. Dose.—Catnip may be given in sweetened infusion in irritation of the respiratory and intestinal mucous membranes, or the tincture may be added to water in the proportion of gtt. x. to gtt. xx. in water giv., and given in teaspoonful doses. It must not be supposed that because catnip is such a common domestic remedy, it is Avorthless, fen* it will sometimes answer a better purpose than the stronger and harsher medicines. Used with the sedatives it gives excellent results in fevers complicated Avith irritation of mucous membranes. Serpentaria. Specific Indications.—The skin is inactive, harsh, desquamatiem of epidermis, epidermis feels rough and dead, Aveight and dragging in the loins, scanty urine, fullness e>f chest, difficult respiration. Dose.—R5 Tinct. Serpentaria gtt. v. to gtt. x., Avater g!v.; a teaspoonful every one to three hours. 94 diseases of children. Belladonna. Though a remedy which is studied with especial reference to the nervous system, it also influences the skin directly, and is thus one of our most important remedies. The reader will remember the statement that " it causes contraction of capillary blood-vessels, and thus overcomes congestion." This is its most important action, and this it does in the skin and kidneys as well as in the brain. Congestion of the skin is known by the deep coloration, dusky red, or Avhen bright red, and the redness is effaced by pressure, a persistent Avhite line is left. In the eruptive fevers its influence is to bring the eruption to the surface. This is shown in the simpler eruptions, erythema and urticaria, and in the severer eruptive fever—scarlatina. Dullness of mind and disposition to sleep are almost always associated Avith congestion of the skin, but in some cases there Avill be marked impairment of the capillary circulation of the skin before the brain suffers. Rhus. This remedy exerts a direct influence upon the skin, being indicated by bright redness and burning pain. It is a rem- edy in hives, with burning and itching; in scarlet fever when the skin is hot, dry and burning; in erysipelas where there is vivid redness with burning pain. Of course we are not altogether guided by symptoms from the skin, though these Avould be sufficient. The sharp stroke of pulse, frontal headache, and prominent red papillae on tip of tongue will be additional indications. Apis. Apis is indicated by itching of the skin or outlets of the body. It is a most valuable remedy when thus indicated, as in "heat," hives, scarlet fever, prurigo, erysipelas and some cases of eczema. Senega. Senega is a stimulant to the skin, and may be em- ployed where there is a feeble circulation, coldness of the extrem- ities, and dry, harsh, dead epidermis. Sulphur. This remedy, which is fully studied under the head of restoratives, exerts a direct influence upon the skin, improving its nutrition and functional activity. Dryness and separation of the epidermis, vesicular or pustular disease, or change of color will indicate it. It has been used both locally and as an internal remedy, and in both ways proves beneficial. infantile therapeutics. 95 Arsenic. Specific Indications.—Inactive skin, wants elas- ticity; dull, salloAV, or pallid color; eczematous eruption; feeble circulation; periodicity not cured by quinine. Dose.—For children, in ordinary cases, I prefer a second or third decimal dilution, though I sometimes use the pellets Avetteel with Fowler's Solution, or Avith a first Homoeopathic dilution. In skin disease where a stronger action is Avanteel Ave prescribe— R> FoAvler's Solution gtt. v. to gtt. x., Avatergiv.; a teaspoonful every four hours, or three times a day. Homoeopathic Indications (3d to 6th decimal).—Great restless- ness and anxiety Avith burning pains, violent thirst with frequent drinking of but little Avater at a time; vomiting and diarrhoea, stools watery, offensive, and undigested, dysenteric stools ; patient Avants to be in a Avarm room, or Avarmly covered ; attacks of anguish, with fear of death ; face pale and haggard, great exhaus- tion ; suppression of the urine or bloody urine; oppressed breath- ing, oedema of the eyelids, urticaria, eczema, pityriasis, falling out of the hair, trembling, stiffness and contraction of the joints; aggravation of symptoms after midnight, on lying doAvn Avith the head low, and in the cold air.—Ehrmann. anti-zymotics. We have been in the habit of classifying such remedies as oppose the putrefactive process in blood as anti-septics, but it is better perhaps to study them as antizymotics. Zymosis is more like a process of fermentation ; as Dr. Dunglison defines it, it is " any epidemic, endemic, contagious, or sporadic affection, Avhich is produced by some morbific principle acting on the organism similar to a ferment—as the major exanthemata." The symptoms of zymosis are prostration and impairment of life, and those that are usually designated as typhoid. The tongue is dirty, or the coatings are brown or deep colored; in the first case the tongue is moist, and in the second it is inclined to be dry. In both cases sordes accumulate around teeth and gums, and the discharges from the body become peculiarly offensive. The causes of zymosis it is claimed, act similarly to if not as ferments, setting up in any fluids of the body septic proe-esses which produce material like the original. Thus the poison of tvphoiel fever introduced into the body will grow a condition of disease like the original, and will generate a poison similar to 96 diseases of children. that introduced. We notice the same in erysipelas, in zymotic dysentery, in diphtheria, anel in other diseases. An anti-zymotic is a remedy, therefore, which, introduced into the body (blood), will antagonize such ferment, and arrest the process that is going on to the destruction of life. In the case of some of these remedies, Ave can see how they act, for they will stop the process of fermentation outside of the body as Avell as Avithin. But in others, we can not tell Iioav this is accomplished, because the remedy has no chemical action, and is used in very minute doses. But whether Ave can account for this action or not, if experience proves that definite results follow the administration of a remedy, Ave should be satisfied to give it Avhen indicated. It Avill also be noticeel that we have a group of these remedies, all antidoting the process of zymosis, yet each haA'ing an indi- vidual action, and not being interchangeable one for the other. Indeed, they are so different in their construction that we Avould hardly expect them to act in a similar manner. As Ave can not interchange them, and must have the right remedy, if Ave wish good results, Ave Avill be especially careful in examining the symptoms that point to the remedy. The remedies Ave will study under this head are :— Acids, Sulphurous Acid, Hydrochloric Acid, Baptisia, Sulphate of Soda, Chlorate of Potash. Phytolacca. Acids. AVe have studied these under the head of remedies that influence the respiratory function, to which the reader is referred, but it is well to examine them in this relation. The indications for their use is, a deep-red color of tongue and mucous membranes, the tongue being usually dry and contracted, coated brown, or slick and like raAV beef; deep redness of parts, when blood comes freely to the surface, may also be noted. As muriatic acid is studied separately Ave will notice here that acetic and lactic acids will sometimes fulfill the indicatiem. We s give the first in the form of a good sharp cider, which is also a mild stimulant; and the second as Avhey, formed by curdling milk. Both of these will be taken kindly by children, Avhen muriatic acid would be refused. Hydrochloric Acid. Specific Indications.—-The tongue is dry and contracted, and the color deep-red or dusky-red C infantile therapeutics. 97 'ngs of tongue are inclined to be brown, growing darker as the lisease advances, and there is dark se>rdes about the teeth. Dose.—It is added to water so as to make a pleasant drink, a little syrup being added, and given ad libitum. Homoeopathic Indications (3d to 6th decimal).—In typhoid fever, Avhen the patient has a tendency to slide down towards the foot of the bed; great debility; diarrhoea with great itching and soreness of the anus; hemorrhoids excessively painful to the touch, bleeding profusely; involving discharges of feces Avhile urinating; sad and silent during the menses; early and profuse menstruation; scarlet fever, rash intensely red Avith great dizzi- ness ; sore throat, foul breath, acrid discharge from the nose.— Ehrmann. With the indications named no remedy Avill give better satis- faction than this acid. In some cases it seems to do everything that is necessary in the case. It lessens the frequency of the pulse, brings the temperature down, relieves irritation of the nerve centers, places the stomach in better condition for the reception and digestion of food, softens the skin, and aids secre- tion. It makes no difference where or Avhat the disease is, if the remedy is indicated it proves beneficial. Sulphurous Acid. Specific Indications.—The tongue is of normal redness and moist, but dirty, the coating is pasty and sometimes hmks like fecal matter, the tongue is dull anel atonic and has no papillae, the fauces and phaynx full and relaxed, and the mucoid secretion broAvnish and dirty, moist sordes about the teeth, fetid breath. Dose.—This is a feeble acid and may be giATen in doses of gtt. v. to gtt. xx., and the following prescription will be very good for children from tAVO to fiVe years: Ri Sulphurous Acid gj., Avater giij. ; a teaspoonful every three hours. Sulphurous acid is a valuable remedy in diphtheria, cynanche maligna, malignant scarlet fever, in some cases of small pox, and indeeel in any contagious or zymotic disease Avhere the aboAre in- dications are found. It is not only a good remedy Avhen admin- istered internally, but it is also an exe:ellent local application in diphtheria and cynanche, and where a part shows a tendency to brake down. 7 98 diseases of children. Sulphite of Soda. Specific Indications.—The tongue is broad and pallid, the coating pasty, Avhite and dirty, frequently the breath is fetid. Dose.—The dose for a child will be from one to five grains, ac- cording to age, repeated every three hours. If one Avill test the sulphite of soda when indicated as above, he Avill become a convert to specific medication. It acts kindly and directly, not only in controlling zymosis, but on the circula- tion, temperature, nervenis system, and in establishing excretion. It is a fair example of the therapeutic maxim, "Avhen a remedy is indicated by a special symptom or symptoms, it proves curative in any form of disease." Chlorate of Potash. Specific Indications.—Fetid odor, as from cynanche maligna, fetid lochial discharge, as from decom- posing animal matter. As a local application it is indicated by bright redness of parts. Dose.—For internal administration to children the dose Avill vary from one-eighth of a grain to one grain ; as a local applica- tion a solution of grs. x. to grs. xx., in Avater giv. Chlorate of Potash has been so extensively used that there is less need of recommending it to readers, than of caution against its abuse. When indicated it is a most excellent remedy, none better; but when not indicated, especially Avhen tissues are dull and dusky in color, and the patient has a feeble circulation, it may do serious damage. It should be used with great care in the eruptive fevers, or Avhen there is irritation of the kidneys, for it Avill sometimes im- pair the functions of these organs to such an extent that the patient Avill suffer, or may die from uraemia. Baptisia. Specific Indications.—The face is full and purplish, like one Avho has been exposed to severe cold ; the tongue and mucous membrane of fauces and throat are full, and bear the same purplish or leaden discoloration. Dose.—R; Tinct. Baptisia gtt. x., Avater giv.; a teaspoonful every hour. Homoeopathic Indications (3d to 6th decimal).—Typhoid symp- toms, dull headache, soreness as if in the brain, sleeplessness, can not go to sleep because " she can not get herself together ;" great dryness of the mouth and tongue, tongue coated, dry and broAvn; INFANTILE THERAPEUTICS. 99 putrid, offensive breath, very fetid stools, preceded by colicky pains in the hypogastrium.—Ehrmann. The symptoms indicating this remedy are so clear that one can hardly go astray. The first sight of the person is frequently sufficient—the full, discolored face, like one that has been long exposed to cold—if not the bluish or purplish coloration of tongue and mucous membranes, is sufficient. It exerts an ad- mirable influence in typhoid disease, whether fever or inflamma- tion, in some cases of diphtheria and cynanche, and in zymotic dysentery. When the indications are strong it will sometimes do everything that one could expect of medicine—lessening the frequency of the pulse, reducing the temperature, relieving the nervous system, putting the stomach in good condition for the reception of food, and establishing secretion and excretion. Phytolacca. Specific Indications.—There is sore mouth ; small blisters raise on the tongue, mucous membrane of the mouth and fauces; apthae; sore throat; diptheritic exudation; soreness and raAvness of the mucous membrane of the nose; sore lips, they look blanched, and the epidermis separates; enlarge- ment of parotid and submaxillary glands ; the cervial lymphatics are enlarged; disease of the breasts; orchitis. Dose.—Py Tinct. Phytolacca (fresh root) gtt. v. to gtt. x., water giv.; a teaspoonful every one to three hours. Homoeopathic Indications^ (3d to 6th decimal).—Syphilitic and mercurial rheumatism ; nightly pains in the tibia, Avith nodes and irritable ulcers on the leg; sensation of roughness and raAvness in the throat; feeling of a lump in the throat, causing a continu- ous desire to swallow; deep ulcers on the tonsils or base of the tongue; very offensive odor, and great pain on SAvallowing; habitual constipation, feeling of fullness in abdomen before stool; capacious flow of urine; albuminous urine; inflammation, swell- ing and suppuration of the mammae.—Ehrmann. Phytolacca is one of the most certain remedies in the materia medica, meeting the most grave forms of disease. It Is indicated in a large number of cases of diphtheria, and seems to antidote the zymotic cause, and in some seasons Avill cure nearly every case. It is also the remedy for parotitis, or mumps. AVe pre- scribe it fe>r infantile sore mouth Avith most excellent results, as Ave do for the sore nipples of the mother Avhich are associated Avith it. It has a very favorable action in scrofula when it manifests itself in the cervical lymphatics. 100 DISEASES OF CHILDREN. ANTISEPTICS. AVe will embrace in this group those agents which destroy septic poisons, and arrest the processes of sepsis outside of the body. The classification may not be the best, but I hope it will not create confusion. The anti-zymotics are really antiseptics, though as Ave are in the habit of studying a group of diseases as produced by zymotic poisons, and their influence upon the body as zymosis, it is quite as well to think of the internal remedies which meet this as anti-zymotics. In medicine, cleanliness takes precedence of godliness, and many times the need of antiseptics may be prevented by strict attention to cleanliness. There is an intimate relation between " dirt and disease," especially if the dirt is the waste of the human body, or that which it subsists upon. Soap and Avater will stand first in the list of antiseptics. Good air is a requisite of good life, and many germs of disease overtake people and gain entrance to their bodies through bad air. The air is defiled in many ways, and all these should be thought of and avoided. The sick should have their supply from such sources as Avill give it as pure as possible. Whilst air is admitted to the room, from Avithout, provision should be made for the egress of the air that has been used. An open fire-place Avith a fire is the best means of ventilation in ordinary houses; if stoves must be used, they should have the doors open so as to permit a draught. Fecal matter is especially poisonous in zymotic disease, and should be removed from the room at once, and the vessels thoroughly cleansed and possibly disinfected. AVhen removed, care should be taken that it is not emptied where it will defile the Avater supply, either by running into the well, or into some stream which supplies other persons. We Avill study the following antiseptics :— Thymol, Sulphate of Iron, Chloride of Lime, Carbolic Acid, Sulphurous Acid, Chloride of Lead, Permanganate of Potash, Liquor Sodae Chlorinatse. Thymol. Thymol, in Aveak solution in alcohol and water, is used as an antiseptic dressing to wounds and in surgical opera- tions, or to abscesses Avhen they are discharging. Thymol may also be used to disinfect the chamber utensils, and dressings for wounds. In some cases the object is to prevent infection by INFANTILE THERAPEUTICS. 101 septic germs, in others it is to arrest putrescence in a feeble part. It may be used of the strength of—R; Thymol gr. ij. to gr. iv., alcohol gss., Avater giijss. Carbolic Acid. Carbolic acid may sometimes be used Avith advantage to arrest the process of sepsis in injuries and surgical operations, and as an excitant to feeble parts. Usually we pre- scribe—!R; Carbolic Acid 5j., Glycerine gj., Avater gv. Mix. In this strength Carbolic Acid is an excellent dressing for burns anel scalds. AVe employ this acid in full strength to destroy warts, working it down to the base of the growth Avith a pine pencil. It causes suppuration, and in this the growth is permanently removed. Sulphate of Iron. Sulphate of Iron in solution is a fair disinfectant for privies, drains, Avater closets, chamber utensils, etc., though it is not as good as the other named. Sulphurous Acid. This remedy, studied with the anti- zymotics, is also a most excellent antiseptic; boAvels may be cleared Avith it, a diseased surface sponged with it, dressing thoroughly disinfected with it, and finally, if used with a spray apparatus, the air may be disinfected. The old method of burning sulphur in a room answers an ex- cellent purpose. It is easily done by holding a pan, containing the sulphur, over the chimney of a coal oil lamp. In the olden time they sprinkled the sublimed sulphur o\ev a pan of live coals. In cases of very severe small-pox I haATe seen the air so freshened by burning sulphur that the patient was improved within an hour. Chloride of Lime. I like the old antiseptic, Chloride of Lime, quite as Avell as any for the disinfection of water closets, drains, sewers and privies, and sennetimes to purify the air of rooms. This agent should be fresh, and as they now put it up in pound and half pound cans, it can be procured and used of full strength. For use in the house it may be placed in a saucer and sprinkled with vinegar. Liquor Sod.e Chlorinate. The officinal solution of chlo- rinated soda is a valuable disinfectant and antiseptic. It is especially useful to cleanse vessels, surgical dressings and band- ages, water closets, drains and sewers; used Avith an atomizer or 102 DISEASES OF CHILDREN. spray apparatus it will purify the air of a room and destroy dis- ease germs. In severe diphtheria, in scarlatina maligna, and small-pox, its frequent use is of advantage to the patient, and prevents the spread of the contagion. Chloride of Lead. Take of Nitrate of Lead half a drachm, dissolve it in a pint of boiling Avater; disolve two drachms of common salt in a bucket of Avater, and pour the two solutions together. The clear, supernatent fluid will be a saturated solu- tion of chloride of lead. " A cloth dipped in this solution and hung up in a room will sweeten a fetid atmosphere instantane- ously ; or the solution thrown doAvn a sink or water closet or drain, or over &. heap of refuse, will produce a like result." It is a cheap disinfectant and antiseptic, and may be used freely at but little expense. Permanganate of Potash. We rarely employ the perman- ganates internally on account of their irritant action upon the stomach. But as a local application to arrest the septic process, and to prevent rapid destruction of tissue, it has no superior. It is used in superficial and phlegmonous erysipelas, suppurative skin diseases, in the treatment of superficial inflammations Avhen parts manifest debility, in the treatment of abscesses, and other suppurations the result of inflammation, and the treatment of wounds and injuries. The solution for external use will be made in the proportion of from one-half to one drachm of the salt to one pint of Avater. When the tissues are greatly debilitated it may be used as strong as ten grains to the ounce of water. ANTI- RHEUMATICS. We have a peculiar inflammatory process which we call rheu- matic, and a variety of pain Avhich we also call rheumatic, and both of these are due to a special cause. Not only have we rheumatic inflammation and rheumatic pain, but we frequently find the rheumatic cause influencing other diseases. What this cause is, is not accurately known. It has been thought to be lactic acid generated during retrograde metamorphosis, or by decomposition or mal-digestion of food. Whether lactic acid or not, it is certainly a product of retrograde metamorphosis or food decomposition, and may be acid in one case, an ammonia product in another, and neutral in another. Whatever it is, how- ever, it is specific in its nature, and is met by specific remedies. INFANTILE THERAPEUTICS. 103 We might have studied this group of remedies under the head of "rheumatism," but I think it will serve our purpose better to examine them here, especially because Ave empk>y them in dis- eases that Avould not be called rheumatic. Then again, these remedies have other actions that are important, and Ave can see them all to better advantage. The group of anti-rheumatics will be as folloAvs:— Macrotys, Sticta, Salicylic Acid, Bryonia, Apocynum, Alkalies. Phytolacca, Acids, Macrotys. Specific Indications.—Muscular pain, pain is in- termittent, as if due to muscular contraction, parts swollen tense, pain sonieAvhat throbbing (no evidence of suppuration), pains in inguinal region and groins, lumbar pains. Dose.—R Tinct. Macrotys gtt. a^., Avater giv. ; a teaspoonful eA^ery one to three hours. AVith the indications as above named Macrotys is a very cer- tain anti-rheumatic. As there is fever and inflammation, Ave usually associate it with the Veratrum. In some seasons it seems to be indicated in almost every case of rheumatism or rheumatic pain, so that we are inclined to think that it will cure every case, anel possibly the next year the disease has so changed that it will relieve none. Bryonia. This remedy has been fully studied, and Ave notice it here only as it influences rheumatism. The indications are sharp pain, the serous membranes are involved, the pain is ten- sive, the pulse is full and hard, and the patient inclined to cough. Apocynum. Apocynum Avas studied under the head of reme- dies Avhich influence the circulation. The indications for it in rheumatism and rheumatic pains are—oedema of feet, eyelids or other part, and puffiness or oedema of part affected. Salicylic Acid. Specific Indications.— The tongue is full, leaden-colored or purplish, the temperature high, but Avithout dryness of the skin ; the breath is sometimes fetid; the tongue is broad Avith leaden pallor. Dose.—The best form to administer Salicylic Acid to children is as a Salicylate of Potash, say—Fy Salicylic Acid gr. x. to grs. xx., Acetate of Potash gss., water giv. ; dose half teaspoonful 104 DISEASES of children. to one teaspoonful e\*ery two or three hours. As a local applica- tian it may be solved with Borax or Chlorate of Potash, the first being the best antiseptic, as—Py Salicylic Acid grs. v. to grs. x., Borax or Chlorate of Potash grs. x., Avater giv. Where the case is properly selected Salicylic Acid loAvers the temperature, controls the circulation, and the specific gravity of the urine is markedly increased. But Avhen not indicated it irritates the nervous system. As a local application Ave employ it in the treatment of nasal catarrh, and in diseases of the throat Avith muco-purulent secretion. It is a good local remedy in some cases of cynanche maligna, malignant scarlatina and diphtheria. In these cases it is used with a spray apparatus. AVith Borax it may be used as a dressing to Avounds and superficial inflamma- tions, if the parts are relaxed and atonic. Phytolacca. This remedy, studied under the head of anti- zymotics is also an anti-rheumatic, if the indications for it are present: Pale tongue, sore mouth, vesicular eruption on tongue and about the mouth, enlargement of lymphatic glands. Sticta. Sticta P*ulmonaria, studied under the head of remedies that influence the respiratory apparatus, is a most excellent anti- rheumatic if the following symptoms present: The neck is stiff and painful, the head draAvn back or to one side, pain in shoulders extending to neck and occiput. Acids. If one has read the medical journals of the past twenty-five years, he will be surprised at what seems to be a fashion in the selection of remedies. For months, the medical journals will teem Avith articles in favor of acids in the treatment of rheumatism, and reports of cures; and then it all seems to change, and alkaline salts are just as strongly recommended and quite as many cases reported. It is all rheumatism, and nothing is said about a difference of cases, and we might suppose it Avas all chance. Yet the cases cured by acids could not be reached by alkalies, and vice versa. We have no doubt of the cures in both cases, for it is a fact that acids will relieve rheumatism, as it is equally the fact that the cause of rheumatism may be antagonized by alkalies. But these are not the same conditions of disease. Lemon juice is anti-rheumatic Avhen the tongue is markedly red INFANTILE THERAPEUTICS. 105 and the papillae prominent; the coating of the tongue is usually thin and white. Alkaline Salts. If the tongue is broad and pallid, we use an alkaline salt, and sometimes it is all that we require to cure any rheumatism. It is usually bicarbonate of soda to the ex- tent of one-half to one drachm daily for children two years old. If the tongue has a leaden pallor, nitrate or acetate of potash are the better remedies. ANTIPERIODICS. If physicians will not concede anything else, they will con- cede that the group of remedies called antiperiodic, and quinine especially, has specific action. They Avill go further, Avhen pressed, and admit a well defined and positive indication for this group of remedies. Pushed a little further, and they will admit the certainty of its action when thus clearly indicated. This is Avhat we claim Avith reference to all remedies Avhich have been carefully studied, and Ave believe that any one may satisfy himself that Ave live in a Avorld of law, medically as well as physically, the same causes always producing the same effects. The indication fir the antiperiodics—periodicity of disease—is so clearly defineel in many cases, that he Avho runs may read. There are exacerbations of the disease, Avhatever it may be, and there are remissions or intermissions in it. The most common type of periodic disease is intermittent fever or ague, a chill or cold stage, a hot stage, a sweating stage, and period of intermis- sion. There is usually regularity in the recurrence of them, so that the disease having made one " revolution," the time of each may be predicted. It would be interesting and pre>fitable to know the cause of periodic disease—the malarial poison—not that it would enable us to treat it better, but that we might the better avoid it, or possibly remove it. But in so far as the administration of reme- dies is concerned, the essential thing is to determine periodicity as the basis of diseased action. Whilst physicians Avill admit the positive action of antiperiodics . in malarial disease, and claim that they are as nearly " specifics" as anything we have in the materia medica, they will yet confess to a great many failures. These failures prove to them that " there is no certainty in medicine;" the quinine cures the ague 136 DISEASES OF CHILDREN. to-day, it fails to-morroAV; it cures Smith, Jones continues to shake (?). Here the diagnosis has been half made. In the one case thee periodic cause, Avhatever it may be, was the basis of the disease ; in the other case it Avas but a part, and there Avas something else at the bottom. There are many cases in which the antiperiodic cannot act, because of some morbid conditions of the body; correct these wrongs, and at once it acts kindly. Proper prepara- tion for the action of the antiperiodic is many times essential to its success. The remedies Ave will study in this connection are :— Quinia Sulph. Arsenic, Alstonia Constricta, Cinchonidia, Uvedalia, Nitric Acid. Quinia Sulphas. Specific Indications.—There is distinct periodicity in the disease, Avhatever else may be its character, the periodicity being marked by exacerbations and remissions, or intermissions. Dose.—In the ordinary use of the remedy the antiperiodic quantity Avill be one grain for the first year, two grains for the second, and so increase one grain each year up to the fifth or sixth, Avhen the dose will vary according to the strength and development of the person. In some cases very minute doses prove antiperiodic; in others its limited absorption by the skin when used as an inunction, or applied to the skin with alcohol, is sufficient. Periodicity being the indication, we want to knoAV if the patient is in such condition that the remedy will act, and will act kindly. In this case, as in many others, a remedy must gain entrance to the blooel before it can antagonize the disease. AVe put it in the stomach in an insoluble form—the stomach must first furnish an acid menstruum for its solution, and then reverse the process of osmosis to cause its absorption. If either of these fail, the agent will not prove curative ; indeed, we might as Avell put it in the patient's shoes. Again, the remedy acts kindly in a certain condition of body, unkindly in other conditions, and a knowledge of these is essen- tial to its right use. We say that if the pulse is soft, the skin soft, inclined to moisture, the tongue moist and cleaning, and the nervous system free from irritation, quinine Avill act kindly, and if there is periodicity, will arrest the disease. On the contrary, if the pulse INFANTILE THERAPEUTICS. 107 is frequent and hard, the skin dry and constricted, the tongue dry, and the nervous system excited, it will do the patient harm. It is true that in some severe periodic disease, quinine will lessen the frequency of the pulse, bring down the temperature, control irritation of the nervous system, and start secretion, but this is an exception to the general rule. In many cases of marked periodic disease, Ave first prepare the patient for the kindly action of the remedy, and then administer it. The child has its Aconite or Veratrum to control the circu- i lation, baths to influence the temperature, Gelseminum, Rhus, Belladonna, or whatever may be needed to relieve the nervous system, and sometimes means to promote secretion. The use of quinine by inunction is an important means in the treatment of children. In many cases of distinct malarial dis- ease the remedy seems to be quite as efficient an antiperiodic, as if given by mouth. In nervous persons, and when the remedy unpleasantly influences the nervous system it does much better. In obscure periodic disease, and when the nervous system requires stimulation, it Avill be found an excellent method of treatment Whilst I regard quinine as a most valuable remedy, in its place, I insist on the indication, periodicity, for its administration. It will not cure continued or typhoid fever; it never has arrested a case, and never will, but it has done an immense amount of harm, intensifying the disease, increasing the suffering, prolonging the duration, and increasing the death-rate. Neither should it be useel as a stomachic or tonic, for it is neither. It is a stimu- lant to the nerve centers in some cases, but the indications for this use are as yet unknown. Cinciionidia. Cinchonidia possesses the same properties as • quinine, and has the same indications. It is claimed that it is better tolerated by the stomach, and is more easily taken by children. The dose Avill be the same. Alstonia Constricta. Specific Indications.—The disease is periodic, having exacerbations and remissions, or intermissions; the skin is dirty or tawny, the tongue dirty, and the urine is turbid and deposits a cloudy sediment. Dose.—The dose of Alstonia will be somewhat less than of quinine, sav, one grain the first and second year, and then an increase of half a grain a year. 108 DISEASES OF CHILDREN. Whilst the Alstonia is not so certain an antiperiodic as quinine and the other alkaloids of the Cinchona barks, it stands next to these, and will meet cases where they have failed. If the reader will notice the indications—a dirty, tawny skin, a dirty tongue and mouth, atonic fullness of spleen and liver, he will see that it reaches very unpleasant cases. When it fits the case, it is much more likely to effect a radical cure, in ague, than quinine. Alstonia is also an excellent tonic and restorative in the cases named, stimulating retrograde metamorphosis and excretion, as Avell as nutrition. It is a neAV remedy, and needs further study to determine its full value. Arsenic. Specific Indications.—The pulse is soft and feeble ; skin inelastic, pallid or dirty; tongue pallid and expressionless; eyes dull; tendency to hemorrhage; periodicity in disease. Dose.—We generally employ Fowler's solution, adding from one to five drops to four ounces of water, and giving a teaspoon- ful four times a day. Sometimes pellets wetted Avith Fowler's solution answer a good purpose, and Ave occasionally use the third to the sixth decimal trituration. AVe haATe made a study of this remedy under the head of reme- dies that influence the skin, and need only notice it here as it is antiperiodic and restorative. As a rule, Ave do not employ it in acute ague, or when quinine will cure; it is the old and hard cases, and when other remedies have failed. There is impairment of the vital forces, and marked by the indications given above, Ave use it as a vital stimulant. The reader Avill notice that it is the minute dose that cures, and we do not use it in the old doses for any purpose. Nitric Acid. Specific Indications.—The tongue has a violet color, showing the ordinary redness beneath; sometimes the lips and finger nails will also show this violet coloration. Dose.—Rj Nitric Acid gtt. x., AVater and Syrup aa gj.; one- half to one teaspoonful every three hours. Homoeopathic Indications (3d to 6th decimal).—Irritable dispo- sition ; headache, relieATed on lying down or riding in a carriage • pain in the bones of the skull, Avorse at night; hardness of hear- ing, relieved by riding in a carriage or in the cars; fetid, A-elloAV discharge from the nose, bad odor from the nose, complete ob- struction of the nose ; sore throat on swallowing, with sensation of a sharp splinter in the throat; putrid smell from the mouth • infantile therapeutics. 109 the urine has an offensive, strong odor, resembling horses' urine; bael effects of frost bite; caries.—Ehrmann. Nitric Acid is principally used in chronic ague, though Ave find cases where it will break the paroxysms and cure the acute. The ordinary remeelies have been used Avithout success. If now Ave find the violet coloration of tongue, we may be pretty sure of a cure with this. It is a remedy for any form of disease Avhen this indication is present. It Avill influence the appetite, digestion and blood- making, give a better circulation of blood, and improved waste and excretion. It is one of the remedies recommended for Avhooping cough, and if the indication is present it is very prompt in its action. It is also a very good remedy in chronic bronchitis and some cases of phthisis. Uvedalia. Specific Indications.—Enlargement of the spleen (ague cake), abdomen full and doughy, fullness in hypochondria, enlargement or hypertrophy of any part, if the tissue is atonic, doughy and inelastic. Dose.—For internal administration the dose will vary from the fraction of a drop to five drops. The common use is as a local application, an ointment of Uvedalia being employed. In ague cake, and asthenic inflammations, this ointment is rubbed on anel toasted in Avith a hot iron. This remedy is not properly an antiperiodic except as it influ- ences the spleen, anel by restoring it to a normal condition, removes the cause of the continuance of the ague. For this pur- pose it has no equal. In hypertrophy and inflammatory engorge- ments of parts, Avhen there is marked atony, it has proven a useful remedy. ANTI- ERYSIPELATOUS. This may seem like a singular classification, and the reader may think that this group should have been included Avith the anti-zymotics. But the disease is not always zymotic, and nei- ther can it be classed with diseases of the skin, in so far as its therapeutics arc concerned. The erysipelatous poison is destruc- tive, involves the blooel, mucous membranes, anel secreting or- gans, and deep-seated structures, as Avell as on the skin. If it AA'ere one poison, and the body Avere one, then Ave would need but one remedy. The fact is, hoAVever, that there are a 110 DISEASES of children. number of remedies, and one cannot take the place of the other. AVe use them by special indications; if indicated they are anti- erysipelatous, if not indicated they are of no advantage anel may do harm. One Avill need no better illustration of the truth of specific medication than is shown in the study of this group. If a rem- edy is indicated, and this erysipelatous poison is the basis of the disease, the single remedy does all for the patient that one can ask. If for no other reason than to see this clearly, Ave should make this study. The remedies Ave will study under this head are:— Tinct. Muriate of Iron, Rhus, Veratrum, Sulphite of Soda, Apis. Tinct. Muriate of Iron. Specific Indications.—The tongue is deep red, mucous membranes deep red, the local disease of the skin shows the same deep or dusky redness. Dose.—R; Tinct. Muriate of Iron, 3ij, syrup gij. I give a half teaspoonful to one teaspoonful every two or three hours. As a local application, Py Tinct. Muriate of Iron gss, Glycerine and AVater aa. giij. Mix. AVhen iron is indicated, and it is in a large number of cases, its curative action is Avonderful. Here is a patient with a most intense inflammation of the skin, Avith a frequent, hard pulse, a high temperature, an excited nervous system, a dry, harsh skin, scanty urine, and constipated boAvels, and the intensity of the disease increasing from hour to hour. Muriate of iron is not re- garded as a sedative, yet it brings the circulation and tempera- ture down to the normal standard; it is not thought of as a rem- edy to relieve irritation of the nervous system, and yet it does it promptly; it is not classed with diaphoretics, diuretics, and cathartics, but yet it restores these excretions. At the same time it controls the local disease, relieving irritation and determina- tion of blood, and restores the circulation when it has been im- paired. It has been remarked above that the erysipelatous poison may influence any part, mucous membranes as Avell as skin, glandular structures, and even nerve substance. If we find its evidences say in a sore throat or disease of the stomach or intestines or elseAvhere, Avith an erysipelatous tongue, or erysipelatous spots on the surface, Ave will think of tinct. muriate of iron as a remedy. INFANTILE therapeutics. Ill Sulphite of Soda. This remedy has been thoroughly stud- ied, and we notice it here to show the difference in disease and in remedies, even Avhen cured by one name. Here is a case of ery- sipelas, frequently deep seated, Avith a broad, pallid tongue, dirty, and Ave give sulphite of soda with as prompt relief as Ave had from the muriate of iron in the preceding case. Rhus. If the local disease shoAvs a vivid redness, Avith burn- ing pain, the pulse having a sharp stroke, the tongue showing bright red papillae at tip,with frontal headache, rhus Avill be the remedy. In this case it controls the frequent pulse, giATes free- dom to the circulation, relieves irritation of the nervous system, anel cures the local inflammatory disease of the skin. Apis. The indications for Apis are, itching and burning of the skin, itching and burning of the urinary passages, and pinkish coloration of the part involved. If these indications are found, this remedy gives prompt relief. Veratrum. If the pulse is full and strong, and the part sIioavs the redness of a common acute inflammation, no remedy Avill prove more promptly curative than this. It is given inter- nally in the usual doses, and the part is wetted Avith it, of full strength, or down to one part to seven of water. restoratives. Under this heading might be included all those agencies that improve the life, the poAver to make a body, and that increase its functional activity. Good functional activity comes from good nutrition, and right conditions for the performance of function. We have already seen that a right temperature, a right circula- tion, right innervation, and right excretion, are necessary to healthy life, as is the right quantity and quality of the food, good digestion and blood-making, and right appropriation of the material in the building of tissue. The last of these may be profitably studied under this head. Some of these have been already studied, as food, air and exer- cise, and some of the remedies that aid digestion by mouth, stomach and intestine, and the reader is referred to the chapter on remedies that influence the digestive apparatus, and those which influence the temperature. The agencies that Ave will study here are:— 112 diseases of children. Air, Iron, Cuprum, Light, Phosphorus, Silica, Exercise, Sulphur, Soda, Food, Cod Liver Oil, Lime. Tonics, Air. As a restorative, air is of prime importance, as Avell as a vehicle for the supply of oxygen to the body. Not that the body is able to appropriate its nitrogen, or Avithdraw from it carbon, as do the plants, but it is a stimulant to normal functional activity. We find persons suffering from impaired nutrition Avhen the air is dead, i. e., Avhere its motion is impeded, and Avhen it fails to receive its supply of sunshine. These are relieved by a ste>rm, accompanied by lightning, which revivifies the air. They are also relieved by mountain air, or sea-air, for similar reasons. The air of a house, if it is continuously closed, becomes dead air, eA7en though it is not defiled by human excretion, or other forms of dirt. The air is rejuvenated by being set in active motion, and becomes a prominent restorative. Dead air looks towards impaired functional activity and death, air in motion towards life. Light. All life is from the sun, and it comes to this Avorld in the form of light. Light, therefore, is an essential of life, and all that pertains to it, to the making of a human body, and to human functional activities, as well as to the groAVth of vegetable organisms. If a child or an adult is deprived of light, he suffers as do plants Avhen thus deprived. If one will recall the groAvth of a potato in a cellar, its blanched and feeble appearance, its struggles towards the few rays of light that gain entrance, he can see how a human being will suffer Avhen deprived of this life-giving agent. The human body, like plant life, requires the full ray—Avhite light—for health, though some diseases of the one as of the other are relieved by parts of this ray, as the blue, yelloAv, red, etc. The human boely also requires the direct ray, and can not main- tain a good condition of health if obliged to depend upon re- flected light. It has already been remarked that air deprived of sunlight be- comes dead, the plant deprived of sunlight becomes sickly and eventually dies, and the child deprived of sunlight sickens, and may die from the deprivation. Light is a stimulant, and Ave infantile therapeutics. 113 employ it in diseases of debility. If a child is suffering from asthenic disease, and is cemfined to a room on the north side of the house, or the light is cut off by houses or trees, A\re at once suggest the propriety of such change as will bring sunshine into the room a considerable part of the day. Bitter toniY's and re- storatives have faileel, sunshine is the restorative indicated. We luiATe cases in Avhich the cure comes from the free light out of doors, anel we insist that the little sufferer shall have it every day. In some cases ve use the sun-bath Avith good effect; the entire body, except the head, may be exposed to the direct rays of the sun before a window, or if a part is feeble this only may be exposeel to the sun. In some cases the white ray is broken up, and Ave use but a part of it—this part now has color. If Ave want sedatives, the color is yellow or green ; if stimulation, red or blue. An alter- nate blue and white light exerts a peculiar influence upon the boely, that can hardly be classed as stimulant or sedative. It is stimulant to a plant and improves its nutrition, but upon the human body it seems rather to increase Avaste. If a patient is suffering fremi nervous irritation, or acute local disease, Ave finel that yellow, green or leaden colored Avindow shades, anel wall papers exert a markeelly soothing influence. If on the contrary there is a feeble circulation anel inneiwation, poor nutrition, and general asthenia, we finel benefit from pink or red shades anel papers, and sometimes from blue. It is the same Avith clothing. If an anemic patient is clothed in yellow, I suggest the change to pink or red. Exercise. The necessity of right exercise to health of body has alreaely been referred to, as Avell as the necessity of rest, in conditions of irritation. Every part is made for use, and main- tains its structure because it is rightly used. If it is disused, it is CA'entually lost. Right exercise is as essential to the life of the child as the adult. Nutrition of the body depends upon it, and a good body cannot be grown Avithout it. It is the same of a part, if not used it is atrophied ; and in such cases right exercise becomes a promi- nent restorative. If the exercise can not be taken in the natural Avav, Ave have the parts rubbed and kneaded, and use passive move- ment. Many deformities in childhood grow from disease of parts; they are corrected by exercise, either passi\-e movement or moATement under the influence of the Avill. 114 diseases of children. Food. One of the most important objects in the treatment of disease is to place and keep the stomach in such condition that a portion of food may be taken and digested every day. Foods are e>f two kinds—calorifacient and histogenetic—heat-producing and tissue-making. The first of these is of the most importance is some forms of disease, the last in others. We can not attempt to define the indications for one or the other here, but will give some simple rules which may guide us in selecting and giving food: " 1. Solid food should rarely be given during the progress of an acute disease, as the stomach and digestive organs are not in a condition to furnish the fluids necessary for its proper commi- nution, and hence it does not digest, but decomposes, giving rise to irritation and other annoying results. " 2. As a general rule, the severer the disease, and the fur- ther the system is from a condition of health, the lighter and more diluted should be the food. Thus, in a high grade of fever or inflammation, we Avould give Avhey, toast-Avater, thin farina, or tapioca, weak chicken or mutton broth, etc. " 3. In states of great exhaustion the food should be concen- trated, very nutritious, and yet deprived, as far as possible, of all material that can not be appropriated by the stomach. Thus Ave would give beef essence, concentrated chicken, or mutton tea," farina Avith milk, etc. " 4. In all febrile and inflammatory diseases the food should be gi\Ten atthat period of the day in Avhich there is least vascu- lar and nervous excitement, and it should never be forced on the patient when suffering from high fever. " 5. Never give food Avhen the patient is suffering from severe pain, as at such times it is impossible for the digestive organs to appropriate it. " 6. If the tongue is heavily coated Avith a yelloAvish coat, a bad taste in the mouth, and a feeling of weight and oppression at the stomach, it is better not to give food, or at least give it in a fluid form and in small quantity. " 7. NeArer force food on a patient when his stomach revolts at it, or if it produces nausea, oppression, or pain. It is'much better to wait until medicine or time has placed the stomach in a condition to digest it. " 8. AVhen the digestive poAvers are much impaired, and it is INFANTILE THERAPEUTICS. 115 important to give food to sustain the strength, it should be given in small quantities, and at regular intervals, like medicines. " 9. If there is an absolute demand for nourishment to sustain the strength of the patient, and it can not be given by mouth it is sometimes an excellent plan to administer it as an injection. " 10. Much care is necessary during convalescence from dis- ease that the patient does not eat too much, or that which is indigestible. The digestive organs are hoav enfeebled, and, if overAVorked, there is not only an excess of imperfectly elaborated material taken into the system, but the exhaustion is extended to the entire body, and impairs the functions of other organs and parts." Tonics. Tonics may Avell be classed with restoratives, as the end of both is to improve nutrition. The difficulty in the Avay of the administration of tonics Avith children, is their bitter, un- pleasant taste. Many remedies, therefore, that we should like to use have to be excluded on this account. Quinia. I employ quinia internally in the diseases of children, only for its specitie influence in antagonizing the malarial poison. Though it is one of our most powerful nerve stimulants, and in some cases, aids digestion and nutrition in a marked manner, its taste is so unpleasant as to prevent its ordinary use. In some cases where this stimulant influence upon the nervous system is required, Ave may use the Triple Phosphate of Quinia, Strychnia anel Iron, (Aitkin's Tonic Mixture). It is a powerful remedy, and in many cases it Avill restore the appetite, improve digestion and blood-making, and aid nutrition in a marvelous manner. As the dose for a child need not be more than five or ten drops three times a day, the child will sometimes take it Avithout objection. It may be prescribed as follows : R> Comp. Tonic Mixt. gss., Simple Syrup giss. ; half a teaspoonful three times a day. Collinsonia. The Collinsonia Canadensis is a very valuable remedy, possessing as it does an influence upon several parts of the body. The proportion for a child two years old will be : Rj Tincture Collinsonia gss., Simple Syrup giijss., Mix. ; dose from one-half to one teaspoonful. To improve the appetite and aid digestion it may be adminis- tered in connection Avith iron, cod-liver oil) etc. It is not bitter, 116 DISEASES OF CHILDREN. but quite pleasant to the taste, and sits very kindly upon the stomach. In chronic diseases of the respiratory apparatus it is a favorite remedy, having a specific influence in removing irritation and improving functional activity of all parts supplied by the sympa- thetic system of nerves. Iron. Iron is a most efficient tonic and restorative in child- hood. It can be so prepared as to be readily taken and Avell appropriated by the stomach. As a general rule, it should not be administered Avhile there are evidences of fever, or during the progress of inflammation. And in the treatment of chronic disease it will rarely be of benefit so long as the secretions are locked up. I prefer the folloAving preparations : Rj Tincture of Muriate of Iron oij., Glycerine or Syrup giv.; dose a teaspoonful three or four times a day. R; Citrate of Iron "3ss., Water gj.; dissol ve and add Glycerine or Syrup giij., mix ; dose, a teaspoonful three or four times a day. Phosphorus. Phosphorus may sometimes be employed Avith advantage as a restorative. Different preparations are in use, but I think the best are the Hypophosphite of Lime, Hypophos- phite of Soda, and Compound Syrup of the Hypophosphites. Of the first, the dose wi 11 be one grain; of the second one or tAvo grains; and of the syrup, one-third of a teaspoonful three or four times a day. The indications for the use of phosphorus are, a pale, doughy condition of the skin, cold extremities, abundant pale urine of Ioav specific gravity, and deficient innervation. Sulphur. Though not regarded as a tonic, or even as a restorative, I regard sulphur as a very important restorative in some exceptional cases. It is not A'ery easy to indicate the cases in which it is most useful, but they are those in Avhich there is a deficiency of heat and impairment of muscular poAver. I use it in doses of three to five grains, associated with cod-liver oil, or other fatty material. Cod Liver Oil. This is a Arery important restoratiATe in many cases Avhere the nutritive poAvers are impaired. It furnishes material for combustion, and thus saves the nilrogenized food INFANTILE THERAPEUTICS. 117 and tissues from being burned. It also furnishes food for the nerve centers in a form readily appropriated. Cod-liver oil, Avhen the stomach Avill receive it kindly, is easily digested, and increas- ing the temperature and the innervation of the body, all the functions are better performed. The dose of cod-liver oil for a child tAvo years old, will be a teaspoonful three or four times a day. Cuprum. Specific Indications.—The skin has a taAvny or dirty hue, sometimes greenish, the tongue is pale, and the gums blanched, the pulse is small and soft, and more frequent than usual. Discharges from the boAvels lack color, and if there is diarrhoea, they are pale and like rice Avater. Dose.—!R> Tinct. Acetate of copper (Rademacher's) gtt. x., Avater giv.; a teaspoonful four times a day. Sometimes Ave get the restorative action of copper by having the patient take it in the shape of a greened pickle—a small portion three times a day. Homoeopathic Indications, (3d to 6th decimal).—Spasmodic affec- tions, Avhooping cough Avith spasms, long continued paroxysms of suffocation, cough, much rattling of mucus ; epilepsy ; violent diarrhoea with cramp in the stomach and chest, much flatus with the stool, nausea and vomiting of frothy mucus, sometimes green, metallic taste; pulse small, soft, almost imperceptible; scarlet fever Avhen the rash suddenly disappears, followed by stupor and delirium or convulsions.—Ehrmann. Silica. Specific Indications.—The skin is rough, the epider- mis desquamates, and the hair is harsh; teething is slow, and the tissues feeble. Dose.—I employ the third decimal trituration as a remedy ; usually I order an oatmeal or cracked Avheat diet, or the use of bread from unbolted flour. Homoeopathic Indications (3d to 6th decimal).—Headache with great sensitiveness to a draft of air. Must have the head covered. Great inclination to perspire. Hardness of hearing. Otalgia with stitching pains. Nasal catarrh with offensiA-e odor and loss of smell. Inflamed glandular s\A'ellings. Fistulous ulcers. Ulcers burning, putrid, indedent. Carbuncles. The skin heals badly; a slight injury inclines to suppurate. Bones swollen, inflamed. Caries. AVeakness of the joints, especially the ankle. Feet perspire very much, and smell very offensively. Phthisis 118 DISEASES OF CHILDREN. pulmonalis, Avith great sensitiveness to a draft of air, and profuse night sweats. Soda. This remedy has been studied in two or three places, and Ave only need say here that Avhen the tongue is continuously pallid and broad, it will be found a good remedy. It improves the appetite, digestion and blood-making, and the nutrition of tissues. Lime. Specific Indications.—Acid fermentation in the stomach, food does not digest Avell, colic, green acrid discharges from tile boAvels, inflammation of cellular tissues, boils. Dose.—When Ave wish to influence the digestive tract Ave use lime-water with the milk. If it is for inflammation of the cellular tissues, or boils, Ave may use lime-Avater, or minute doses of sul- phide of lime. PAET II. CARE AND MANAGEMENT OF INFANTS. CHAPTER III. The young of man is the most helpless of all created beings, requiring constant care from the hour of birth until its second Or third year. But it is especially for a short time after birth that it is thought to need extra attention, and Avhen it very frequently gets an officious interference that renders it uncomfortable, and frequently leads to disease. Many of the prejudices and Avhinis of the olden time still re- main, and some of them, indeed, receive the tacit support of the physician. It is Avell to educate the public mind to the truth ■ in these things, and though the physician may find it a thankless task at first, it Avill bring its return in an increased confidence and respect. AVorks on obstetrics point out the things to be done, and how to do them. It will be our business here, at least to some extent, to point out some things that should not be done, and other things that are not done properly. Washing the Child.—A physician should ne>t have the least hesitation in telling a nurse how to Avash the child, if she sIioavs ignorance in regard to it. A ATery common plan is, to rub the child Avith lard freely, and then Avith an ordinary cloth, and poor soap and lukeAvarm Avater, to Avash off the grease and secre- tions upon the skin. It is a difficult job, and the child is rubbed until its skin is irritated, and still not cleansed, and it is ren- dered fretful and uneasy for days. (119) 120 diseases of children. The true Avay is, let the person washing the child rub it thor- oughly with the lard, and then with a piece of soft flannel, or even cotton, wipe the child clean. Then with soap and Avater, and a so/? cloth or sponge, it may be gently yet thoroughly washed. The drying had better be done by gently pressing the towel or cloth upon the skin, rather than by rubbing. This makes all the difference possible in the feelings of the child and its future comfort. Anel as the skin has a very close sympathy with other parts, in addition to being an extremely sensitive part itself, Ave can readily see that, in some cases at least, it will be a means of avoiding serious disease. Clothing of the Child.—I object most decidedly to many parts of the infant's dress, as usually made; and I have no hesi- tation in giving my objections Avords, whenever and wherever I am brought into contact with these errors. The bandage of the child is always pinned too tightly. The child no more needs this swathing than the adult; its abdominal muscles are just as strong, and just as capable of performing their functions. But there is something worse than the mere suffering which folloAvs such confinement. The bandage extends upAvard so as at least to embrace the floating ribs, hence the insertion of the diaphragm, and often much higher. Here there is a more or less serious impairment of the respiratory function, as the band is more or less tightly applied. We not only have suffering and restlessness upon the part of the child from this, but occasionally such impairment of the lungs as will lead to a fatal result. There is another lesion that may be directly attributed to this. I allude to infantile constipation. It comes on gradually; it is attended with colic, and sometimes with infantile dyspepsia. True, in many cases it does not produce any present marked inconveniences, but it lays the foundation for future constipation, hemorrhoids, prolapsus ani, and, as I believe, for hernia. The child needs such band only for the purpose of retaining the dressings of the cord, and to give AA'armth. One thickness i»f soft and^ elastic flannel, not so Avide as to extend upward on the thorax, or down to be Avet Avith the excretions, will answer this purpose. Being elastic, it maintains its place Avithout being applied so tightly. Its skirts are usually as badly made. The waist is made of cotton stuff, usually stiff and harsh, and so wide as to prevent CARE OF INFANTS. 121 any warmth from the flannel attachment. As frequently put on it chafes the child under the arms, and is unpleasantly bulky and cumbersome about the body. The diaper is as bad or Avorse than the remainder. If the parents are in good circumstances, and it is a first child, it will be of linen diaper; at any rate it will be harsher than there is any need for. Let this be Avetted and dried several times Avithout washing, and Ave have a cause of irritation that Avould make the adult Avince if obliged to Avear it. I have seen scores of cases in Avhich irritation and chafing about the genitals, the perineum, nates, and thighs, Avas the result of such treatment. Yet the mother could not imagine why her child should be so affected. While I do not insist that they should be Avashed after each discharge of urine, though it Avould be better and pleasanter for the child if they Avere, I object to their being used until they smell and are as foul as it is possible for so much linen or cotton to get. If children are delicate, the absorption of these excre- tions must prove very detrimental. When a child shows such irritation as I have named, recom- mend that the diapers be made of canton flannel, Avhich is soft, unirritating anel pleasant, and that they be rinsed in clean Avater every time they are soiled, before drying and using. HOW OFTEN SHOULD THE ClIILD BE AVASHED?—The question might be put in a different Avay—not so much how often, but how much should the child be Avashed? Some are Avashed a very great deal ; indeed, some poor innocents have their lives soaked out of them. It would be a mercy to the children to put a few monthly nurses, and not a few mothers, through a similar course of soap and water, as aftenvard they Avould hardly be so free Avith it. I haA'e seen children Avashed out of the Avorld in a feAV months, and sometimes in a feAV weeks, and have had to put a stop to it a number of times. The child is very sensitive to cold, and being entirely divesteel of clothing, and having the evaporation of Avater from the surface for some minutes, is too much for many. To Avash a child properly, the nurse should have a blanket or other woolen material of sufficient size to Avrap the child entirely up. Then a portion of the body should be washed at a time, the child being kept Avell covered in the meaiiAvhile. EATen with this care it is not necessary that the child be washed every day. 122 DISEASES OF CHILDREN. AArashing is done for cleanliness, and need not go further than that; and when children are feeble it had better fall short of it than exceed it. Attention to the Cord.—The question is usually asked, how long Avill it be before the cord falls off? and Avhat shall Ave do with it in the meantime? It usually requires from five to nine days for the separation of the cord, and cicatrization of the umbilicus, and occasionally it is prolonged beyonel this. It is important that the cord be tied sufficiently tight to pre- yent any hemorrhage. True, it is but rare that there is any severe hemorrhage yet I have had such in my practice. But a small amount of blood discharged causes the cord to adhere to the cloth, and the mass becomes hard and unpleasant, if not irritant to the child. I ahvays recommend the young physician to examine the cord before it is dressed, and if not certain in regard to this point, to apply a second ligature. The cloth with Avhich the cord is dressed should have its upper surface oiled (in obstetrics Ave say oil Avhen Ave mean lard), so that it may not adhere if it should become necessary to remove it. Every day Avhen the child is dressed, it should be placed in such a position that there will be no strain upon it. And in washing the chilel, the cord anel cloth should be removed, so as to Avash beneath it. In the majority of cases, irritation and inflammation about the umbilicus is the result of tension upon the cord, upon the dress- ing becoming hard and irritant from bleeding, or other cause, from a too tight band, or from the excretions passing up so as to soil the dressings of the cord, and subsequent want of cleanliness. No traction or other means should be used to remove the cord, as it Avill be separated in due time by the natural process of absorption. When separated it is AveII to apply a soft cotton cloth, folded, that the recent cicatrix may not be disturbed by the rubbing e»f the child's clothes. If the part seems someAvhat tender, a cloth spread Avith mutton suet or simple cerate may be applied. Ulceration of the Umbilicus.—Occasionally Ave are called to prescribe fe>r ulceration, or rather a want of cicatrization of the umbilicus. Sometimes there is considerable redness and evielenccs of inflammatory action, and the chilel is feverish and fretful. I generally prescribe one of three things. In the majority of care of infants. 123 cases, that the part be powdered with subnitrate of bismuth twice daily. If there is much inflammation, that it be dressed with stramonium ointment. Or, if there is an erysipelatous redness, order a solution of permanganate of potash, one grain to the ounce of Avater. If the child is feverish and restless, Ave Avould give Aconite, one tlrop to the ounce of Avater, one-half of a teaspoonful every hour. Excoriation and Chafing.—Various parts of the infant's body may be chafed, and become excoriated, and painful. I have alreaely mentioned the chafing that comes from Avant of attention to the diapers of the child, and want of cleanliness. It is quite easy, by inspection, to determine the nature of the difficulty, but it is not always so easy to give immediate relief. The use of Colgate's Glycerine Soap to Avash the child, and strict attention to cleanliness, will sometimes be all that is neces- sary. Occasionally dusting the inflamed parts with scorched flour Avill ansAver the purpose. The common idea is that some- thing " greasy " is necessary, and frequently ointments will have been used before the physician is spoken to. Mutton suet, if well prepared, ansAvers as Avell as any ointment, if Ave except the glycerole of starch, which is an excellent application in such cases. The most certain, as Avell as the speediest cure, has fol- loAved the use of subnitrate of bismuth in fine powder, dusted over the parts, tAvo or three times a day. Does the Child need Medicines immediately after Birth?—Many persons believe that the young child needs some- thing to act upon its boAvels. And for this purpose they propose to give it urine anel molasses, lard and molasses, or sometimes castor oil. Others think it should have a Avhisky or rum mix- ture, to Avork the mucus out of its throat. The truth is, the less the child is interfered Avith the better it Avill get along. Nature makes provision for all of its wants, and an action of the bowels is provided for in the first milk of the mother. The child Avill have a sufficient opportunity to take medie'ine, Avithout commencing thus early, and it will be good policy to impress this upon the mother and nurse. There is no need of saffron tea to keep off the jaundice, or make the child a better color. No need of German chamomile 124 DISEASES OF CHILDREN. to strengthen its stomach, or of pap or panada, or of any of the hundred and one things that people like to force upon the child. What it Avants is warmth and quiet, and not food or medicine. Nature furnishes food at the proper time, and furnishes it exactly adapted to its Avants. Difficulties in Nursing the Child.—Occasionally Ave find a child that will not nurse, at least it persistently refuses, and accompanies its refusal by energetic remonstrances. This seems, in some cases, an excellent illustration of original sin, though, doubtless, there is some good cause, other than this, if we but kneAv it. If the child is fed the difficulty increases as time progresses; for, becoming accustomed to the spoon or bottle, he is less in- clined to take the breast. The proper Avay is, not to feed the child, but, by kindness and perseverance, get it to nurse. The child should be applied to the breast Avhen in a good humor, and not when crying; sometimes it will be an advantage to Avet the nipple with the milk, as an extra inducement. In some cases the difficulty is Avith the mother, not Avith the child The nipples are retracted, or not properly formed, and the child is unable to obtain a sufficient hold to draAv the milk. In this case a breast-pump, applied for a moment, Avill draw the nipple out so that the child can nurse. If a breast-pump is not at hand, it may be accomplished Avith an ordinary pint bottle; fill it with hot water, and pouring it out quickly, apply to the breast. The sore nipple that is so frequently met Avith, and that proves such an annoyance and source of difficulty in nursing, is best cured by wearing a leaden nipple shield, and small doses of Phy- tolacca with or without Aconite. If sheet-lead can be readily obtained, this may be easily fashioned into a cup that will accu- rately fit the nipple. If not, a piece may be hammered from ordinary bar or other^ lead. We want it to fit accurately and pleasantly, so as to bring it in contact with every part of the nipple. It should not be too heaA'y, as it is to be constantly worn, except when the child is nursing. It has often seemed strange to me that Avith so simple and certain a means of cure, such suffer- ing should be permitted. Food of the Child.—The natural food of the child for the first eight months, is the mother's milk, and it is rarelv the case, when the mother is healthy, that any other food will be required. CARE OF INFANTS. 125 If the mother is healthy, and still fails to supply the amount necessary, the probabilities are that there is a deficiency of some kinds of food. Frequently it Avill be of farinaceous foods, Avhich, if prepared in palatable form, gi\Te an increase of good milk. Occasionally the fault will be found in a lesion of digestion, and the employment of the bitter tonics and restoratives will answer the purpose. AVhen the child can not have its natural food Ave haA'e to advise a substitute. That most readily obtained and easily prepared is the milk of the coav. In its natural condition it is too rich in some of the elements of food, too poor in others. The constitu- ents of human, coav's and goat's milk are as folloAVs: HUMAN. COW. GOAT. Water......................................................883.6.........861.0.........868.0 Butter.................................................,... 25 3......... 38.0......... 33.2 Casein...................................................... 34.3........ 68.0........ 40.2 Sugar of Milk and Extractive Matters.......... 48.2........ 29.0......... 52 8 Fixed Salts................................................ 2.3........ 6.1......... 5.8 To prepare the milk of the coav for food for the child during the first Aveeks of life, one-third the quantity of Avater should be adileel, and one drachm of sugar to the pint of milk, and the Avhole boiled. After the first month, the proportion of Avater may be lessened to one-fourth, and after the child has passed its sixth month it may be given pure. Those avIio have had occasion to use artificial food in raising children, prefer the milk of the goat to the coav, and there is no doubt but that it is more easily appropriated by the child. In France, goats are frequently trained so that they Avill lie doAvn anel permit the child to nurse directly from the udder. Liebio-'s food is a most excellent substitute for the mother's milk, being much better than the milk of the coav. It contains the elements of human milk in a form easily digested by the child. It is composed of Wheaten Flour, two ounces; Barley- malt Flour, tAVO ounces ; anel Bicarbonate of Soda, thirty-one grains. In preparing it for use, the folloAving directions are observed : Take a heaping tablespoonful of the poAvder anel mix it with tAVO tablespoonfuls of Avater; then add to it ten tablespoonfuls of milk and heat the Avhole over a gentle fire (do not boil). AVhen the mass begins to thicken, remove it from the fire, anel stir for five minutes. Then place it o\*er the fire, and heat again, 126 DISEASES OF CHILDREN. with stirring, until it becomes quite fluid, and then suffer it to boil. In the preparing of the food, do not use too much heat, or haste, as it Avill prevent the necessary chemical change taking place. Use a gentle heat, and only allow it to come to a boiling temperature at the end of the process. In employing artificial food, whether milk or that just named, it it better that it be given Avith a nursing bottle, rather than with the spoon. There is more than one reason for this direc- tion, but one good reason is sufficient. The act of sucking calls into use the muscles connected Avith the salivary glands, and ex- cites those glands, hence there is good insalivation of the food. Maw's nursing bottles are decidedly the best, though they require more care to keep them clean and in order. But the ordinary nursing bottle will answer if it is well looked after. Milk should never be alloAved to stand in the bottle, which should be emptied and rinsed every time it is used, and kept in a vessel of Avater, or at least partly filled Avith Avater. In this Avay it is kept clean and sweet. Everything connected with the food of the child should receive the greatest care, and should be frequently scalded. A Arery slight decomposition in the milk, from sourness of a vessel, Avill give the child an indigestion, and may seriously derange the functions of the stomach and boAvels. These facts can not be too forcibly impressed upon those Avho have the nursing of children in this Avay. The food of the child should always be given at the tempera- ture of the body, and this Avill require the employment of heat at all periods of the day. A nursery lamp ansAvers this purpose very Avell, but there is a much simpler means a\Tailable Avherever coal-oil or gas is employed for light. It is a nursery attachment, which may be attached to any lamp or gas-burner, and which Avill hold a cup steadily over the blaze, Avhere it will quickly heat. These are made by Messrs. Tifft & Howard, 406 Pearl street, NeAv York, of Avhom they may be ordered by mail, if they can not be obtained nearer. It seems very important, when trying to raise a child by the milk of the cow, to be able to determine Avhether the milk ob- tained is good. There is a very simple method, Avhich will give this information to any one. Allow the milk to stand for six hours, skim it, and if, upon holding it to the light, the skimmed car:: of infants. 127 milk has the natural color, it is good. But if it is blue, or green, or varies in appearance in any Avay, the milk should be rejected as not fit for the purpose, and another coav's milk should be tried. I need not say that it is important that the chilel should have one coav's milk, and I am satisfied that it is much better if the coav is fresh. As the child attains to the end of its first year, it will require additional food to the mother's milk. If it is strong and healthy it may be gradually accustomed to the ordinary diet of the family; farinaceous food being preferred to animal. If, Iioav- ever, the digestive organs are not strong, it Avill be better to con- fine it to a milk diet, or to food prepared with flour and milk, or Avith sago, tapioca, etc. A AVet Nurse.—Next to the mother's milk as food for the child, the milk of another Avoman is the best, and when a choice can be had, preference should always be given to a Avet-nurse, Mothers have a prejudice to overcome in agreeing to this; yet, as it is manifestly for the child's benefit, and as its chances of living are one hundred per cent, greater, it is a duty to make the sacrifice for the child's benefit. When Ave have really trieel it, having a wet-nurse in the house, and having the care of baby, Avill not be found nearly so objectionable as anticipated. The nurse should be selected with reference to her health, the age of her milk, and Avith reference to her character and associa- tions. AVe do not expect perfection in a Avoman avIio is obliged to take this position, and must make many alloAvances. As a general rule, Ave Avill find the health of persons in the loAArer AA^alks of life much better than those avIio enjoy more of this world's goods and comforts. The general appearance of the patient will usually tell the story at the first glance. Such per- sons are rarely scrofulous, at least to that extent that it would be objectionable, and if they are, they carry the marks in old cica- trices, and enlarged glands. \Vhat Ave are most fearful of is a syphilitic taint, secondary syphilis. AVe may not be able always to determine this, for it may exist in the system, without having as yet shown itself in the usual symptoms. A person suffering from secondary syphilis in the early stage Avill show maculae, and if the tongue is exam- ined Ave will find the evidence in recent or old indurations. The danger of getting a person afflicted Avith syphilis is not 128 diseases of children. great, except in large cities, and even here the pleasures and profits of a life of shame are so much greater than attends the position of a Avet-nurse, that they are not frequent applicants. AVhen there is doubt eif the capacity of the applicant to fur- nish a sufficient supply e)f milk for the child, the breasts may be examined. If round and firm, of usual size, and a Avell devel- oped nipple, there Avill be but little doubt in this respect. It is important that the nipple be free from sores or abrasions, as this not only prevents free nursing, but it is the source from which vices of constitution are most frequently transmitted. It is best that the milk of the wet-nurse be as young as the mother's. AVhen other things are right, three or four Aveeks, or even as many months, may be permitted. I do not see any ob- jection to the milk being too young, if it has passed the first week. As regards the character of the Avet-nurse, we would like to have it as good as possible, as Avell as her associations. Still, beggars can not ahvays be choosers; we Avant to save the life of the child, and Avet-nurses are not too plenty, and Ave may, by kindness and good offices, improve both character and associations. AVeaning the Child.—Almost all the Avorks that speak of weaning the child, name tAvelve months as the period the child should nurse. This, hoAveA7er, is English and continental authority, and is not ahvays adapted to this country and our habits. If a child is Avell developed, and has cut its teeth thus far without trouble, there is no reason, so far as it is concerned, Avhy it should not be Aveaned. Of course it is essential that for a couple of months it has been accustomed to eating, and has digested its food Avell. I do not think weaning is prudent until Ave ha\Te the conditions named. If, as in some cases, the milk of the mother is found to disa- gree Avith the child, it may be Aveaned at a much earlier period, and will thrive better on the milk of the cow, or the other foods named, than if permitted to nurse. Not unfrequently the moth- er's milk undergoes a change from the eighth to the fourteenth month, that renders it poorly adapted to the wants of the child, and gives rise to various symptoms of infantile dyspepsia, and to irritability of the bowels. The re-appearance of the menstrual discharge sometimes pro- duces a very marked effect upon the milk, and in nearly all cases CARE OF INFANTS. 129 impairs its value. But as this, in the usual course of events, does not appear until the chilel has attained the age of one year to eighteen months, it is not often that our attention will be called to it. When, from such reason, there is evident change in the milk, and it gives rise to gastro-intestinal or other disease, Ave will advise Aveaning the child. AVhen the mother becennes pregnant while nursing, the milk very generally suffers after a time. It is necessary in this case that the chilel be Aveaned, not only for its own sake, but for the mother's; for nursing a child Avould interfere with the natural progress of gestation. The objections to Aveaning the child are of two kinds—Avith reference to the mother, and Avith reference to the child. The first objection woulel seem trivial, if Ave did not so often Avitncss the health of t".e mother completely broken down by frequent child-bearing. It is the popular impression, and to some extent it is true, that so long as a woman nurses her child, she will not have her menstrual periods, and so long she will not be in dan- ger of becoming pregnant. Frequent pregnancies are a very great burden to a woman, especially if she has not the pmper assistance in the care of her family, anel Ave need not AveHieler that she prefers to nurse one child for tAVO or three years, rather than have another added to her cares. The objections upon the part of the child are with reference to its health, and its poAvers of digestion and assimilation iirmain- 'ainmg a separate existence. In some families e\Tery jhilel has to pass through a second summer of cholera infantum, Avhich requires great care, especially Avith regard to its food. In such cases it is best for the child to nurse eighteen months, or even two years. In other cases the infant is far from robust, and its develop- ment is sIoav ; it cuts its teeth tardily, does not digest food well, and is liable to attacks of gastro-intestinal irritation. Here, also, nursing the chilel should be prolonged. AVhen it is determined to Avean the child, there is much dis- cussion of hoio it is to be done, as it is no easy matter in many cases, and, as usually managed, very troublesome in most. Trying to " taper off," as a drunkard tries to quit drinking, giving the chilel a little now and then, or depriving him of it in the day-time, giving it to him at night, is just about as efficient in the one case as in the other. At the end of a AA'eek the child 9 130 DISEASES OF CHILDREN. is no nearer weaned than Avhen it commenced; but in most cases is farther from it, for it has been Avorried and tantalized until it has a stronger desire for the breast than before the weaning commenced. It is also a poor plan to put bitter or nauseous things on the nipple, thinking to disgust the child, and make it reject the breast. AVhile it answers occasionally, it fails in the majority of cases. It is objectionable, also, because it makes a bad impres- sion upon the child's mind, and it feels that it has been deceived, anel wronged. The only true Avay is, to stop giATing the breast at once, and convince the child that this is right. In the day there Avill be but little trouble, and if the father or some friend will take care ' of the child for two or three nights, the trouble will be all over. The moral effect of such a course upon the child will be a decided benefit, and Avill giAre the mother a power of control that she could not otherAvise pe)ssess. Sleeping.—The young child should be accustomed to regular periods of sleep during the day, indeed, all its habits should have great regularity. As it groAvs older it does not need so much sleep, and after it has passed its first year, it will not usually require more than one sleep in the day-time. At night the child should have its separate bed. I think it very objectionable for the child to sleep Avith its parents. Expe- rience has proven that the young yield vitality to the older, and the sound to the unsound. This Avould be a very cogent reason if either of the parents suffered from ill health. But beyond this it is not Avell for the chilel to breathe the emanations from the bodies of other persons, as it must, if thus confined, and fre- quently covered so as to almost exclude the air. Another, and a very important reason is, that if alloAved to lie with the mother all night, it will obtain a habit of frequent nursing that will proA'e detrimental to its oavii health and to the health of the mother. Many times an infantile dyspepsia may be traced to this source. Let the child lie in its crib or cradle at the bedside, and Avhen it requires nursing the mother can take it in the bed Avith her and give it the breast, placing it in the cradle again afterward. A child cared for in this way will be much less trouble to the mother, in addition to the advantage to its OAvn health. CARE OF INFANTS. 131 Regular Habits.—There are feAV persons that can be con- vinced how readily a child may be trained to regular habits, in all things, unless they have seen it. Very frequently they will not believe the evidence of their own eyes, but account for it by saying, that it is OAving to a difference in children, some being good, others being bad. The truth is, that a child is just as sensible to impressions as the adult, and is just as ready to yield obedience if it is asked in a proper manner. Beyond this is the fact, that habits in childhood are very readily formed, and very persistently maintained. This is as true of bad habits as of good. During the first three months the child should be accustomed to taking the breast about every three hours, and at very regular intervals. As it groAVS older it will not require it more than four times during the day, and once at night. One-half the slight illnesses, and the irritability and fretfulness of childhood might be avoideel in this Avay. Nursing the chilel Avhenever it cries, simply to keep it quiet, is a most pernicious habit, and will Arery certainly lead to ill health, usually in the form of infantile dyspepsia and colic. And yet this is a very common habit, and will require much effort upon the part of the mother to break it up. The time of getting up in the morning, of being Avashed and dressed, of taking the morning sleep, of the afternoon sleep, should all be as regular as the clock. I knoAV that the physician a-ill be met by many objections Avhen he urges this ; the most common being, that the mother has other duties besides taking care of her child, and the attention it requires can not always be giA'en at the minute. The fact is, however, that duties regularly performed become light by the side of those irregularly done. No one ever accomplishes much, unless the work is pursued by system. So in this case, it is a saving of time to do things promptly to the minute, and have the child in good humor and take its long refreshing sleeps, rather than from neglect, to have it irritable and fretful, difficult to get to sleep and hard to keep asleep. There is no necessity of rocking a child when sleeping, indeed but little necessity of their being rocked at any time. If they , are accustomed to go to sleep at a certain time, all that is required is to owe them the breast, and put them in the crib or the bed. Americans might learn a valuable lesson from our German citizens, in regard to the management of young children. They 132 diseases of children. put them in the crib and cradle and cover them Avarmly, and keep them there, except Avhen nursed. There seems te> be no trouble about it, the child is comfortable, is acoustenneel te) that method of living, and takes it as quietly as if it were its natural moele of existence. When it becomes old enough to play, a tassel, with some simple tews, is suspended within reach of its hands, and with them it Avill amuse itself for hours at a time. When olel enough to sit alone, it is accustomed to amuse itself in a similar Avay. MORAL GOVERNMENT. As the health of the child will depend to a considerable extent upon the condition of the nervous system, especially of the brain, the physician will frequently have to givre the mother instructions in regard to its moral government; especially Avill this be the case Avhen the child is suffering from chronic disease, Avhich is aggravated by irritability, displays of temper, and the various cryings and frettings so common in badly-regulated households. True, in these'cases he is not able to effect as much by good advice as he Avould like; yet, there are other cases in which he may, by a few judicious words of counsel, direct the mother, avIio is willing, Iioav to train her child, so as to conduce to her happi- ness as Avell as its oavii. In this respect, the experience of a mother has higher value than any other person, and I Avill give the short chapter from Chambers' Infant Treatment, by the lady editor of that Avork: "During the first feAV Aveeks of life, happiness is solely derived from the healthy operation of the bodily functions. Until the senses begin to act so as to convey impressions to the brain, there can be no pleasure drawn from external circumstances. The activity of the senses, and the enjoyment produced, Avill be in proportion to the state of the health. An infant avIio is continu- ally in pain, either crying, moaning, or in a state of repletion, or of exhaustion from the consequences of suffering, will be but little attracted by the light, sound, or motion Avhich first engages the senses of infancy. In no other instance, perhaps, are the influ- ences of the physical condition so immediate and so evident. An infant, even of three Aveeks old, will exhibit a haggard, grief-Avorn countenance, sunken eyes anel shrunken face, painful to those Avhose experience tells them Avhat these signs indicate. But the CARE OF INFANTS. 133 fair, plump, contented look of the healthy babe, speaks a lan- guage of comfort, prophetic e)f the approaching ehnvn of intellect. " The general irritability caused by disordered functions, ren- ders the impressions upon the senses even more painful than pleasurable; the disposition for enjoyment bestOAved by the feel- ing of health is denied ; the mother's voice, her smile, are asso- ciated Avith pain as much as with pleasure, and the affections are imperfectly and tardily aroused. As weeks pass on, habits form, anel instead of a habit of eemtentment, there is one e>f fretfulness. An infant so constituted is either reared Avith an indifference to its continual crying and fretfulness, or with the apprehension Avhich causes its nurse to be continually seeking Iioav she may quiet or prevent its cries. At the age when foe>d alone appeases it, the babe is always eating or sucking ; as it grows older, sugar, cake, etc., are superadded, with the addition of noises or rough exercise, and but too frequently some sedative or composing draught, Avhich the mother believes herself obliged to adopt in order to procure the child needful repose, or the servant surrep- titiously administers to relieve herself from incessant fatigue. When the time arrives that restraints and guidance should be adopted, the fear of farther irritation by contraction leads to a system of bribes, eleceit, and coaxing; all the loAvest sentiments of human nature are appealeel to; and at two years old Ave have a selfish, willful, ill-tempered child, with viedence apportioned to its strength, and intelligence prompted by ill feelings. It is ne>t to be supposed that these moral disorders belong exclusively to bad health. A healthy child may be selfish, willful and ill- tempered at tAvo years of age, if injudicious treatment have cultivated the loAver sentiments ; but the healthy infant is predis- posed to receive happy impressions, anel enjoys the condition called good temper—a term Avhich in infancy is synonymous with gooel health. The nurse has fewer temptations to mismanagement, and the affections and intelligence being more healthful and aetiA-e, moral mismanagement actually produces less permanent injury. "There can not, then, be too much value attached to the physical condition of an infant; to the condition of the parent while pregnant and Avhile nursing, and to the regulation of every particular connected with the health of her offspring. This being the first object, both in point of time and importance, the next consideration is the means of developing the moral and intellectual faculties." PAET III. DISEASES OF CHILDHOOD. CHAPTER IV. The diseases of childhood do not differ in their pathology from the diseases of the adult. In each disease, there is a de- pression of the vitality, either of the Avhole or of a part, and though there may be increased functional activity in some par- ticular functions or part, we must never take it as an indication of an increased vitality or of a real functional increase. The animal body in early life is immature in all its parts, anel Avhat change there may be in the character of diseased action, is in part dependent upon this. The tenacity to life is just as strong in the child, in many cases even stronger than in the adult. Possibly, this increased tenacity of life, will counter- balance the iiniuaturity of organs, in all children avIio possess vitality sufficient to reach adult years. There is this fact to be taken into consideration in all our estimates of infantile disease: That there is a certain proportion e>f children, Avho are ne>t born with sufficient vitality to live longer than the secemd year, and some, indeed, avIio have not the capacity to live this long It is not Avorth our while here to discuss to any considerable length Avhy this is so, but it concerns us to knoAV that it is a fact, and to knoAV how Ave may determine it. It is a Avell-known fact in ATegetable physiology that imperfect or unsound seed Avill not produce perfect plants; and that Avhen the seed-bearing plant requires to be fertilized by the pollen of another, an unsoundness of this Avill lead to deterioration ; that in breeding animals, sound and robust young are not expected (134) PHYSIOLOGICAL MARRIAGE. 135 from immature or unhealthy parents ; and that peculiarities anel imperfections Avill be increased from generation to generation, by propagating from animals thus impaired. In our civilization there is a continual breeding in, with refer- ence to physical and vital imperfections, and hence to save the integrity of the species, it is necessary that the imperfect young should die before they have arrived at an age to transmit their physical imperfections. Physiological Marriage.—Prof. William Byrd Powell advanced the theory, that persons of similar temperaments could not have healthy offspring, or in some cases, Avoulel not be capa- ble of begetting children ; even two very healthy persons, physi- cally and mentally well-developed, anel Avith each the capacity to live the allotted time of man, might have children that Avould not live to the age of two years, or in se>me cases Avould not have the capacity for independent existence at all. The principles of this discovery, if discovery it is, are thus briefly stated by Prof. Powell: "Law I. AVhen the constitutional similitude of the respective sexes is such that a qualified observer can not detect an appre- ciable difference, sterility Avill be the result of their marriage. Illustration: AVashington and his Avife Avere, respectively, san- guine, and it is knoAvn that sterility Avas the result. Between General Jackson and his Avife there was a nominal difference of constitution; he Avas bilious sanguine, and she Avas bilious; nevertheless they Avere physically the same, both being exclu- sively vital, and it is knoAvn that sterility was the result. The first Napoleon and Josephine Avere, in person, greatly different, and in constitution they Avere nominally as different, and yet there Avas no physiological difference. He Avas sanguine enceph- alo-bilious lymphatic, and she avus bilious encephalic, conse- quently they Avere, respectively, compounded of equal varieties of vital and non-vital conditions, and it is knoAvn that sterility was the result of their alliance. "LaavII. When the constitutional similitude of the respec- tive sexes is less than complete, or is appreciably different, progeny will result, but it will be dead-born, imbecile, scrofulous, deaf, blind, or otherwise imperfect. Illustration: I can furnish three hundred examples of this la\A', but as they are not histori- 136 diseases of children. cally knoAvn, they Avould be of no value in this relation. I can cite one, however, which is historically known, viz.: the first Napedeon and his secemd Avife. Her teinperaineut Avas bilious encephalo-sanguine, and his temperament I have indicated. There Avas betAvecn them an appreciable difference e)f constitu- tion, anel the result of this difference Avas one son ; but the dif- ference Avas too small to secure to him a normal viability, for he died of a scrofulous affection of the lungs, at the age of eighteen years. It is most indisputably the fact, that a considerable differ- ence of constitution must obtain betAveen the respective parties to a marriage, to secure to offspring a soundly viable constitu- N tion. To discover the least difference consistent with a physiolo- gical marriage Avas indispensible, but before discovering this the conviction became forced upon me that my discovery could ne>t become of general utility Avithout the discovery of a huv of universal application. By a great amount of observation and study, I succeeded in discovering the desired huv, and it is of easy application, and Avill universally secure a physiologically legitimate offspring, and the greatest possible happiness to the parents. Those, therefore, avIio make domestic happiness, and a really useful progeny, conditions of marriage, must observe the folloAving laAV : " Law III. One of the parties must be exclusively vital—that is, must be either sanguine, bilious, or sanguine-bilious (the last being a compound of the tAVO former, is also vital), and the other party must as certainly be more or less non-vital, that is, more en- less lymphatic or encephalic. All marriages, in contra- vention of this laAV, are physiologically incestuous, and the con- sequences will be vicious in proportion to the delinquency. " Law IV. The greatest dissimilitude of constitution that can obtain between the sexes, when they are respectively of the same species, is that Avhich obtains betAveen a vital and a non-vital temperament—and this is the most favorable to progeny. But marriages of this character are greatly impracticable in any country. It is a very remarkable fact in the physiology of hu- man procreation, that a high degree of constitutional dissimi!- tuele is about equally unfavorable to progeny. It has been seen that a high degree of similitude entails a scrofulous diathesis, and with a high degree of dissimilitude, as when one party is Avhiteanel the other negro, the progeny is invariably scrofulous, I believe." TEMPERATURE, ETC. 137 Life Line.—To determine whether a child has the power to live to adult years, is of much moment if it is practicable. Most persons judge by the general appearance, and by the functional activity of the important organs. A physician in active practice for a number of years, will be able to form a very good opinion in most cases, but will occasionally be seriously in error. I have been accustomed to place much reliance upon a meas- urement of the base of the brain, which determines its depth. Let the meatus auditorius externus represent the floor of the cranium, which it does only approximately, and a line drawn from the occipital protuberance to the external angular process of the os-frontis where it articulates Avith the malar bone, repre- sent the superior part of the basilar brain, as marked by the tentorium cerebelli. The measurement betAveen the tAvo is approxi- mately the depth of the base of the brain. If the measurement is one-half inch or more, the child has the capacity to live to adult years, and Avill pass safely through any ordinary sickness. If the measurement is from three-fourths of an inch to an inch, it will live Avhen it Avould seem hardly possible. But if the life line fall beloAV the measurement of one- half inch, the poAver of living is feeble, and the child will succumb to the slightest ailments, and with one-fourth or even one-third of an inch, Ave may safely say that life is not possible. As a physician's success Avill, to a certain extent, depend upon his poAvers of prognosis, such knoAvledge as this Avill prove of much importance. It tells us when Ave may rely on treatment to effect recovery, and when the best treatment will fail of success. For the general pathology of elisease, and the principles upon Avhich Ave base our practice, the reader is referred to my " Prin- ciples of Medicine." TEMPERATURE. PULSE. RESPIRATION. In an abnormal condition of the system, the first things to be considered are, the temperature, pulse and respiration. Pulse and respiration are more readily affected, and to a greater extent, than the temperature, but the latter affords a more correct diag- nosis of the patient's condition than the former. The pulse may deviate from a healthy standard, from senne trivial cause as that of anger, slight indigestion, and sometimes sleep will produce a change, but under such circumstances the trouble will be of no 138 diseases of children. moment and soon subside. However, should a change Oi tem- perature occur and remain for a time, a general abnormal condi- tion will prevail. Too much importance, then, can not be attached to the stuely of the temperature, and a thorough knoAvledge in disease of the body thermoneter. TABLE Showing the Temperature, Pulse and Respiration at various Ages. PULSE. RESPIRATION. Temperature above normal age, at birth, 1.5 120 to 150 40 to 60 1st month, .5 120 40 1st year, .25 105 to 130 30 to 40 15th year, .21 75 to 85 20 21st year, .0 70 to 75 16 to 18 Deviations from this table have been fenmd Avithout any con- stitutional disturbance, but they Avere feAV, and so far as tests have extended it is accurate. Temperature.—Exercise and diet, as Avell as climate, may affect and cause the temperature to vary, but it will be but a tem- porary change when thus disturbed. Should it, hoAvever, deviate, and remain so for some hours, we may expect an abnormal con- dition of the system. If, on the day folloAving Ave note an in- crease in the temperature, running as high or higher than that of the day preceeding, the question of disease is beyond all deuibt. In measles there is usually a high temperature three or four days preceding the eruption ; in scarlet fever it is less a day, perhaps; in variola tAvo days; in whooping-cough, the first indication of the disease is, a change in temperature usually running quite high ; in diphtheria it precedes the soreness of throat. Increase of temperature calls for sedatives and cooling remedies. Decrease of temperature demands stimulants and sustaining treatment. The following things are to be taken into special consideration : The hour at Avhich the temperature rises or falls. An increase of temperature, beginning a little earlier each day, is cause for alarm, beginning later is encouraging. A decrease, beginning earlier each day is a good indication, beginning later, it is to be closely watched; also the duration of temperature. Should a high temperature prevail anel remain Avithout a dee-line for senne time, it is to be regarded as ATery unfaA'orable. LikeAvise a low temperature, remaining so for a time or continuing to elecrease, is to be considered a most dangerous symptom, being of greater danger than a corresponding rise Avould be—the danger lying temperature—pulse. 139 in the great depression, and probable Avant of vital force neces- sary to accomplish a reaction. The daily fluctuations of tem- perature should be carefully noted, going frequently from one point to another, and not remaining stationary any given time. The food of the child has an influence on the temperature; after a good nourishing meal, there Avill be a rise in the index of the thermometer; if there is no rise, the food does not contain sufficient nourishing properties. This rise Avill not exceed .5, unless in a case Hearing starvation, Avhen it may be increased. A too simulating food Avill produce a rise of one degree in the temperature; after digestieui there Avill be a decrease of tempera- ture until the normal standard is reached. Pulse.—As previously said the pulse is more easily disturbed than the temperature, and an increase may be occasioned by the most trivial cause. The position of the body influences the pulse, it being augmented Avhen the body is in a standing posi- tion, and decreased Avhen lying down. Joy, grief and anger will vary the pulsations of the body; food likeAvise affects it. Hence, an accelerated pulse must not ahvays be regarded with alarm; but Avhen such a condition supervenes with general constitutional disturbance, it demands investigation. In studying the pulse Ave Avant to note the frequency, regularity and fullness. Referring to the table Ave find that in a healthy adult there are from 70 to 75 pulsations per minute ; Ave note the fact on the living body, anel finding it to correspond, Ave next observe the regularity, Avhether the pulsations are uniform in volume and time, or Avhether there is an irregular action of the heart, causing the pulse to intermit. Fullness of pulse is ascertained by the sensation imparted to the finger from the current of blood as it passes through the artery. If a large portion of the pulsation is felt, Ave get fullness, but if the finger discovers but a small portion of it Ave have the reverse; likeAvise we detect a hard pulse, soft pulse, and a wiry pulse, and measure them according to the standard of increase, decrease anel perversion. AVith children it is more difficult to obtain accu- rately the number of pulsations to the minute, but the general character e>f the pulse is to be taken into consideration in order to determine the departure from a normal condition. If pe>ssible observe the pulse Avhile the chilel is sleeping. The pulsations will be more accurate than when the little sufferer is aAvake and irritable. 140 DISEASES OF CHILDREN. Respiration.—In disease we not only desire to Iciioav the number e)f respirations per minute, Avhether there is an increase or decrease, but Ave must as fully understand the character and source of respiration ; Avhether it occurs Avith regularity, e>r Avhether it is panting and short; Avhether it is abdominal or thoracic, and wliether a full inspiration can be taken Avithout causing pain. Note, if any, the difference in the character of respiration Avhen the child is sleeping and Avhen awake; also the sounds, if any, produced by respiration. Observations made during sleep are generally more accurate than made Avhen the child is aAvake, as any exertion quickens the respiration. CLASSIFICATION OF DISEASE. It is most convenient, and at the same time the most suc- cessful plan to study disease as it influences particular parts or functions. AVe thus get all the diseases of a part in a group, and are able to learn better the differential diagnosis between them, and also betAveen them and others of different parts. There are certain diseases that are general in their character, and have their cause principally in the blood, or in functions intimately associated Avith it—as blood-making, nutrition, and retrograde metamorphosis. This will naturally form the first division. We may then study diseases of the digestive organs in a group, next, diseases of the respiratory organs, then diseases of the kidneys, of the skin, of the locomotive apparatus, of the nervous system, and of the organs of special sense. -------- m •-------- CHAPTER V. FEBRILE DISEASES. Fever is a disease involving to a greater or less extent every function of the body. Continuing for a time, it impairs the tissues, in some cases to such an extent that the further continu- ance of life is impossible. The functional derangement is studied by the rule of excess, defect and perversion, though in all cases the change is in reality an impairment, and is associated Avith depression of vitality. FEBRILE DISEASES. 141 In analyzing a simple fever, Ave find it composed of: 1st. An excess in the frequency of the pulse, an excess in the temperature of the body, anel an excess of innervation. 2d. A defect of excre- tion by the skin, the kidneys, and the boAvels, and a defect of digestion, assimilation and nutrition. 3d. A perversion of the blood and of some functions. Pathology of Fever.—The doctrine of the humoralist that fever is a disease of the blood, offers the best explanation of the phenomena of feA'er, and leads to the most certain methods of treatment. AVe must not forget, however, that Avith such de- rangement of function, especially of Avaste and excretion, and its complement nutrition, the solids of the body are being diseased from day to day. In some fevers, the cause of the disease has been influencing the functions of nutrition and waste for a considerable time before the outbreak of the fever, and during this time all the tissues Avhich have been formed are more or less diseased. In such a fev^r, complete recovery does not take place until all such intu the softPtisf extent; anel in those exceptional cases, Avhere the patient does not h)sc flesh during the progress of the disease, a perfect recovery does not take place; the reason is obvious—the itnperfecAissues remain in their place, and to that extent the nutritivefprocess fails. The old tissue is.incapable of functional activity,J^d hence the imperfection Avith Avhich all the processes of life are performed. If Ave regard the cause of fever, as acting in and from the blood, as consisting of some morbid material, either generated within the body, or introduced from without, but ahvays acting to impair the quality of this fluid, and consequently depressing every functional activity, we have a plain and very simple pathology. AVe can readily see how such condition of the blood should occasion the disturbance of the circulation that we witness, and how this abnormal circulation should be the cause of the diminished functional activity of every part of the body. Based upon this view of the pathology of fever, the treatment becomes also simple and straight-fonvard. The rapid but im- perfect circulation of the blooel is corrected by certain sppc'al medicines, called sedatives. The excretory organs can then be tissue is ♦efinoved. Thiuttrfri typhoid fever, Ave find the disease continuiu*fBLuntil the softPtissues have been removed to a very 142 diseases of children. stimulated by remedies that act directly upon them to increased activity, and any morbid material thus removed. AVe are then in a position to call the digestive organs into action, and obtain normal nutrition of tissue. Lastly, Ave have a class of remedies which directly influence zymotic processes and products, and in some cases at least, are antidotal to the cause of disease. In other words, they are agents which, Avhen introduced into the blood, combine Avith and modify or destroy all those activities which are unnatural to and not under the control of the vital forces. As before remarked, Ave must not lose sight of the structural changes which go on,during the incubation and progress of the fever, and which impair the integrity of the tissues. But the treatment for this is as distinct as for the other. This imperfect tissue must be removed, and the nutritive process must be stimu- lated to its repair. The remedies which increase excretion favor retrograde metamorphosis, and the tAvo go on together. A tonic and restorative treatment, Avith a good diet, completes the treat- ment, and the tAvo go on harmoniously together. As the old tissue is removed by the first, neAV material is prepared, and formed into tissue in its place by the second means. AVe have thus, as Dr. Chambers tersely expresses it, a real " reneAval of life." Classification of Fevers.—We may divide the fevers of childhood into four ATarieties. The evanescent, or febricula ; the periodic or malarial feA^ers, divided into two varieties, intermit- tent and remittent; continued fever, and the eruptive fevers. FEBRICULA. Occupying a prominent place in the diseases of childhood, if Ave regard the percentage of cases, is this little fever. I call it little on account of its brief duration, and the little danger that attends it. In the apparent symptoms it may be, and frequently is, a very high or active fever, and gives rise to much uneasiness on the part of parents. Causes.—The causes of febricula are numerous, but why they influence the system in this Avay is not Avell known. Probably, the most frequent cause is the action of cold arresting secretion from the skin. The similar arrest of secretion from the kidneys physiological marriage. 143 or boAvels may produce the same effect. In other cases, an indis- cretion of diet, folloAved by imperfect digestion, introduces into the blood an imperfectly-formed material, Avhich must be removed. Pathology.—Taking the humoral view of this disease, Ave regard it as being produced by a morbid material in the circula- tion. In the first case, from retained excretions; in the second, from mal-digestion. This vieAV is borne out by the history of the disease—ahvays terminating by the re-establishment of secre- tion, and by the treatment, which is ahvays successful Avhen it attains this end. We do not Avish to ignore the existence of the nervous system in this vieAV, for it is influenced by the cause of fryer, and in some cases its morbid action is capable of generat- ing such a blood-poison, but usually this is but a minor element. Symptoms.—The symptoms of febricxda are those common to all fevers. The patient has a chill of longer or shorter duration, but not usually of much severity. Preceding this chill, it will be observed, sometimes for a few hours, that the chilel is dull anel languid, cross, or that it wants to sleep more than usual. FolloAving the chill, the pulse increases in frequency, and the temperature becomes higher, the secretions are checked, and there is more or less excitement of the nervous system. The febrile reaction comes up rapidly, and usually attains its greatest intensity in from tAvo to four hours. It may continue to the termination of the disease as a continued feA^er, or it may be broken up into exacerbations and remissions. The natural duration of the disease is from one to three days, the fever gradually declining for the last third of the time, anel finally terminating by the establishment of free secretion. Occasionally, during its progress, the excitation of the nervous system becomes very great, and the child suffers severely from this, and in some cases, may have convulsions. In other cases there is determination of blood to the brain. Diagnosis.—There is no difficulty in determining that the chilel has fever, for all the symptoms are very clearly defined. But it is not so easy, always, to determine the character of the disease. The points that I rely upon to effect this diagnosis are tiiese: though the skin is hot, it is never dry or harsh; the tono-ue is uniformly moist, anel the mucous membranes of natural color; though the pulse is frequent, it is not othei'Avise much 144 diseases of children. changed, but gives a sensation to the finger of normal feillncss, and freedom of circulation. As the reverse of this is shenvn in the more persistent fevers, the diagnosis is quite plain. Prognosis.—The prognosis is favorable whether the patient has treatment or not, and Ave can safely say that the disease will terminate favorably by the close of the third day. Treatment.—If secretion is arrested, Ave Avant to look to that, and usually but little additional treatment will be necessary. For the excited circulation anel to favor diaphoresis, add Aconite gtt, v. Asclepias, gtt. x. to xv., to half a glass Avater, and give in teaspoonful doses every hour until a good action has been ob- taiued. If there is irritation of nervous system, alternate Gelse- minum Avith the sedative, gtt. x. to xv. to water §iv., a teaspoonful every tAvo hours. If the chilel is vigorous, a warm bath may be given once a day, but if delicate the dry rubbing or the employment of some oily preparation is far better. INTERMITTENT FEVERS. It is only in those sections of county Avhere the malarial poi- son is intense, that young children have ague; and during the first six months, they rarely have it, even in these localities. After the child has passed the age of tAvo years, the system seems more easily impressed, though not so easily as after the age of puberty. Cause.—The cause of intermittent fever is generally conceded to be a poison generated by the decomposition of vegetable mat- ter, and receives the name of " vegetable malaria." Pathology.—There is no doubt but that the cause of inter- mittent fever acts upon the blooel, and from it upon other parts and functions. There is ahA'ays a period of incubation in Avhich the morbid material, Avhatever it may be, is increasing. Finally it produces depression of the vital powers, and a chill. Then the vitality of the system seems concentrated for its removal, anel Ave have the febrile reaction, succeeded by the SAveating stage, in Avhich secretion is re-established. The system thus freed from the poison enjoys a period of com- parative health (the intermission), but the germs of the poison TEMPERATURE, ETC. 145 stiil remaining in the body, it is gradually reproduced, and there is another period of depression, reaction, and secretion. Thus it may continue for an indefinite time, the system never freeing itself entirely from the cause of the disease. Symptoms.—An intermittent fever in the chilel, presents the s.une symptoms, and in the same order as in the adult. There is a period of elepressiou for a short time, in Avhich the child is dull, its face pallid, the extremities cold, and the lips anel finger nails bluish. The chill is thus introduced, and increases in intei - sity for a longer or shorter time. The child is seen to be cold, has more or less rigors, its pulse is small and increased in fre- quency, and the secretions lockeel up. Continuing thus for a short time (from fifteen minutes to tAvo or three hours), the symptoms of the chill gradually pass away, the surface becemies Avarm, loses its bluish appearance, the pulse increases in frequency, and the symptoms e>f nervous depression pass away. But going beyond the point of healthy reaction, the surface becomes hot and more or less dry, the pulse increased in frequency from twenty to forty beats per minute beyond the healthy standard, anel is also changed as to freedom, and is more or less hard, and the nervous system is excited, with a gradual increase in the febrile symptoms. The fever attains its maxi- mum intensity in from tAvo to six hours, and there is then a like gradual decline to the sweating stage. This stage e>f an intermittent is announced by the diminished frequency of the pulse, anel disappearance of nervous excitement. The temperature of the body is reduced, and the child breaks out into a free perspiration, and there is also increased secretion from the kidneys. There is then a complete intermission, the child presenting no evidences of elisease feu* tAventy-four, forty-eight, or seventy-two hours, as the fever is quotidian, tertian, or quartan in type, except in some rare cases in Avhich it assumes the form of a double quo- tidian, there being tAvo revolutions of the fever each day. This period being passed, there is again a recurrence of the phenomena of chill, febrile reaction, sweating stage, and inter- mission, until finally the fever Avears itself or the patient out, or is arrested by medicine. AVith Nervous Complication.—In some cases the nervous system suffers severely. There is very great depression during 10 146 diseases of children. the chill, with tendency to congestion. And during the febrile reaction there is dullness, Avith tendency to coma. In other eases there is very great excitation of the nervous system, with deter- mination to the nerve-centers. And this will sometimes con- tinue during the intermission. In some cases the ague is attended with convulsions. AVith Inflammatory Complication.— In other cases Ave notice a very high febrile reaction, the fever being prolonged beyond the usual time. The SAA'eating stage is imperfect, and during the intermission the child still suffers, the skin is dry, the urine scanty, and the pulse somewhat hard. AVith Gastric Complication.— In still other cases, the stomach and associate organs seem to suffer severely. In some the stomach is very irritable, and there is nausea and vomiting during the chill and early part of the febrile reaction. And even in the remission, the irritability of the stomach remains, so that digestion is imperfectly performed, and medicine is not received kindly, and is absorbed sloAvly and Avith difficulty. In another class of cases the tongue is pale, broad, and coated Avith a white, or yellowish-Avhite, tenacious fur. The appetite is capricious, digestion imperfect, and nutrition of tissue is not well performed. Medicine is received Avith difficulty, and if ab- sorbed at all, sloAvly, and does not act kindly, or produce its usual influence. , In still another class of cases the mucous membranes are darker, even dusky, and the coatings of the tongue are also dark-colored. Digestion is imperfect, anel of course nutrition is to a considerable extent suspended. In the severer cases there is a tendency to septic decomposition. And in all, the usual antiperiodic treatment fails to arrest the disease. Treatment.—During the chill the child must be kept Avarm ; this may be aided by giving Avarm drink occasionally, and there is nothing better, especially if the child craves drink, than hot lemonade, SAveetened just enough to make a pleasant drink, and let it be taken at pleasure. It will proATe a grateful and effie:ient remedy. As soon as reaction takes place, give the required seda- tive with any other remedy that may be indicated. Acemite, if the pulse is small and rapid and there are no complications. Veratrum, if the pulse is full and bounding and with gastric INTERMITTENT fever. 147 complication. Asclepias is the child's diaphoretic and an essential part of the treatment, when the skin is harsh and dry; Gelse- minum is always to be thought of Avhen the pupils are contracted and face flushed, Avith irritation of nervous system. If there is dullness with a tendency to sleep, indicating congestion, Bella- donna in small doses, gtt. iv. to viii. to Avater 5iv., a teaspoonful every half hour or hour, according to the severity of the case, Avill prove a fine remedial agent. As soon as the pulse and tem- perature begin to decline and secretion is established, the anti- periodic is to be given. In uncomplicated cases carbazotate of ammonia is preferable to quinia ; it may be given even during the fever with perfect safety. The dose is small, from one-eighth to one-sixth of a grain, triturated with sugar of milk and given every three hours. AVhen complications exist, and particularly if there is considerable depression, quinia is preferable to any other antiperiodic. It may be given in from one to tAvo grain doses, repeated every tAvo hours during the intermission. After the chill is broken, anel especially in malarial localities, it is best to continue the antiperiodic for three or four days, giving it less frequently, liOAvever, in one grain doses twice daily, repeating it en the seventh day. Quinia is the antiperiodic, though there are other remedies that act in the same manner, but less efficiently. I prefer to give a sufficient quantity in a single dose, rather than in broken doses. This for a chilel tAvo years old, Avill be from two to three grains. It is given best in a cold infusion of green tea. If the chill is broken, it may be repeated for tAvo or three days in one-grain doses. For some days aftenvards, it Avill be Avell to continue the Veratrum or Aconite, and in a malarial country repeat the antiperiodic every seventh day. In the nervous complication, with dullness, and congestion of the nerve-centers, I use Belladonna, associated Avith Aconite, as in this formula : R> Aconite, Belladonna, aa. gtt. v. Avater *iv.; a teaspoonful every hour during fever, and every three hours during the intermission. Rhus tox. Avill be found indispensable in some nervous compli- cations ; give it in alternation or with the Aconite. Stimulant frictions to the skin, as Avith a combination of some of the essential oils with lard, is an aid to the treatment. This means is continued until the symptoms are no longer marked during the intermission, and then quinine is given as before. 148 diseases of children. In the second form—Avith irritation e>f the nervous system anel determination of blood—I prescribe: ly Tincture of Gelseminum gtt. x. te) xx. ; Aconite or Veratrum gtt. y. ; water ,5iv. A tea- spoonful is given every hour while there is fever, and every tAvo hours during the remission. If the symptoms have been very severe, the acetate of potash may be given for a day or two be- fore the administration of the antiperiodic. In the case of inflammatory intermittent, the administration of the special sedatives, until a complete sweating stage and inter- mission is produced, Avill frequently be all that is required. In the more persistent cases, gently opening the boAvels, and the use of a solution of acetate of potash, will be necessary. The im- portant point in all of these cases is, not to give the quinine until the system is thoroughly prepared for its reception. The gasti'ic complication gives the greatest trouble, as there is not only imperfect digestion and nutrition, but medicines are not absorbed from the stomach. In the first case named, I should give the patient Nux in small doses every hour, and the usual doses of Aconite Avith Gelseminum. The chilel may have a hot foot-bath once or twice a day, or sometimes a general hot bath. Cold applications over the stomach Avill usually ansAver a better purpose than counter irritants. In severe persistent cases the folloAving local application will relieve Avhen all other means fail: Take of cinnamon, cloves and alspice aa., sufficient quantity, cover Avith good Avhisky and Avater, equal parts, and onake an infusion, strain and keep it hot, Avring flannel cloths out of this and apply to the epigastric region ; it Avill quickly relieA'e and refresh the little sufferers. AVhen the tongue is broad, and coated Avith the pasty coat, I advise the administration of sulphite of soda in doses of tAvo to four grains, every two or three hours. AVhen this condition is very marked, anel the disease has continueel for some time, a thorough emetic is the shortest road to a cure. In the meaiiAvhile, the child should have Veratrum in small doses regularly, and if there is nervous irritability, Gelseminum. AVhen there is the dusky discoloration of the mucous mem- branes, the patient Avants Baptisia anel Aconite every hour, anel the quinine should be given in the form of an elixir, prepared Avith muriatic or nitric acid and simple syrup. This avi'11 supply the required acid; and render the antiperiodic ready for immediate absorption. REMITTENT FEVER. 149 Where quinia can not be given by mouth, I frequently arrest the disease by its endermic use. Especially in the nervous and gastric forms of the disease,'this method will be found beneficial. I e>reler : R Quinia Sul. 5j., Adeps, or Avarm olive oil, §ij. Let the child be thoroughly rubbed with this tAvice daily ; brisk friction Avhile it is being employed is of great importance. I have not failed of success in any case, with this method, Avhere the internal treatment had been pursued as I have recommended. MASKED INTERMITTENT. In the diseases of children, as Avith the adult, Ave meet Avith many cases, in Avhich, if the periodic influence is not the cause of the disease, it continues it, and prevents success from the ordinary treatment. Many of these cases are very obscure, *and it will require that the practitioner be impressed Avith the im- portance of closely looking for the malarial complication, that it be eletected. Almost all of the inflammatory diseases may b", thus compli- cated, and Ave frequently find it at the bottom of persistent gas- tric and intestinal disturbance, and of lesions of innervation, and especially of nutrition. In the adult Ave find the majority of masked intermittents in the form of neuralgias. The treatment of these cases will be the same as for an ordi- nary intermittent, and quinia, one to two grains in the fe>rm of an elixir, may be given with an aciel; or carbazotate of ammonia or Alstonia may be given, in the following doses: grains two of the first eATery tAvo hours ; from one-sixth to one-fourth grain of the second every three hours, and one to three grains of the last four times a day. REMITTENT FEVFR. The fevers of childhood are almost always remittent in form. A continued fever, being of very rare occurrence. Thus Ave Avill have remittent fever from the ordinary malarial cause of this disease in the adult, and also from the various causes which may give rise to fever. The disease is divided into t\Aro varieties, regular infantile remittent, an el slow infantile remittent fever. The first possesses all the elements of a fever, and runs a regular and uniform 150 DISEASES OF CHILDREN. course; while the second is defective in many e>f its symptoms, and is irregular in its course and duration. We Avill consider the regular form of the disease first. Causes.—As just remarked, the causes of infantile remittent fever are of two kinds. In a certain proporthui of cases, it is as distinctly malarial, as in the same form of the disease in the adult. I knoAV of no means of determining this cause, other than that it prevails in localities and at times when the adult remittent fever is noticed. The ordinary cause of continued and typhoid fever in the adult—animal malaria—Avill produce a species of remittent fever in the child. The ordinary causes of simple fever, cold, arrest of secretion, imperfect digestion, defi- cient waste of tissue, Avhatever may be their origin, will give ris ry a p pa rat us. With Disease of the Brain.—There are two principal lesiems of the brain, noticed early in the disease. These are— irritation Avith determination of blood, and congestion. In the first case, the child is noticed to be more than usually restless and fretful, its eyes are bright, and it is continually Avanting drink, and various things that it sees. In a short time it is noticed that the face and scalp are flushed, the head is hotter than usual, the eyes are bright, Avith contracted pupils, and the restlessness has increased. The disturbance thus commenceel may go on to the development of inflammation, or after lasting for some time—three or four days—may terminate in congestion and coma ; or in other cases, the excitement may eArentuate in the production of convulsions. In the second case, the chilel is dull, anel has a tendency to sleep much, but sleeps with its eyes partly opened. The eyes are 152 DISEASES OF CHILDREN. dull, pupils frequently dilated, and the face has a heavy, expres- sionless appearance. As the case progresses, coma comes on, and gradually deepens until it becomes impossible to arouse the child from it. AVith Derangement of the Digestive Organs.—The common lesions of this apparatus are—irritation of the stomach, and atony e)f the stomach with morbid- accumulations. The irritable stomach is readily recognized in most cases. The child can not take food, drink, or medicine, Avithout nausea and retch- ing. The tongue is elongated and pointed, tip anel edges more or less reddened, and the coating—usually Avhite—confined to its center. In the second case there is also nausea and efforts at \*omiting, food is not digested, and medicine produces sickness and is not absorbed. The tongue is unusually pale, broad, anel covered with a pasty white coat. In both of these cases, the elisease runs its course more rapidly. Not only on account of the sympathetic derangements that Aoav from such gastric disturbance, but also because digestion is arrested, and all our means of cure are inefficient because not absorbed. AVith Disease of the Respiratory Apparatus.—In the Avinter and spring, infantile remittent fever is frequently compli- cated with disease of the respiratory organs. In the majority of cases, it is nothing more than an irritation, with a more or less troublesome cough. In others, a well developed bronchitis, and in others, a lobular pneumonia is set up. The symptoms are usually very plain. The chilel has cough, Avith increased frequency of respiration, and sometimes slight difficulty in breathing. At first there is dryness of the bronchial mucous membrane, afterAvard increased secretion. Where these symptoms are marked, a physical examination of the chest should be made, to determine the character of the trouble. Diagnosis.— The diagnosis of an infantile remitttent fever is easily made. From febricula, Ave determine it by the dry skin, hard pulse, and dry or broad and pale tongue. From continued fever, by the regular appearance of remissions. From inflam- matory diseases, by the absence of local symptoms ; for even when complicated, the local symptoms are distinctly secondary. REMITTENT FEVER. 153 Prognosis.—The prognosis is favorable. Unless the compli- cations arc severe, there is little danger of a fatal termination in viable children. As heretofore noticed, a certain proportion of children are won-viable, and will die of any disease, or even Avithout any disease, before they have passed the age of child- hood. The mortality to be expected in the course of ordinary practice will be from tAvo to five per cent., depending upon the fact just stated. Treatment.—The treatment of a remittent fever is usually very simple, and also very successful. The first object is to reduce the pulse to the normal standard, and get a free anel equal circulation of blood. The second, to remove any irritation or other derangement of the nervous system. The third, to estab- ish secretion, anel get a good condition of the digestive apparatus. The fourth, the employment of agents to antagonize the malarial or other cause of disease. The first indication is very surely accomplished by the use of the special sedatives, and the accessory means—a general bath once or twice daily, and the hot foot-bath. I usually prescribe : Py Tincture of Aconite or Tincture of Veratrum Airide gtt. v. to gtt. x., Avater 5iv.; a teaspoonful every hour. The action of these remedies should not be looked for at once ; they require time, but it is noticed that under their use there is a continuous amendment in all the symptoms. In the course of forty-eight hours, the febrile reaction has to a considerable extent subsided, the pulse is but little above the normal standard, and the circu- lation is free and uniform; and Ave are ready to look after the second indication. As a general thing, Ave Avill not need to use any special reme- dies to relieve the nervous system, for any irritation or other disturbance will pass aAvay with the febrile reaction. The special cases that demand treatment will be named hereafter. The third indication is also frequently fulfilled by the action of the special sedatives, Avithout other means. But Avhen secre- tion is not established as we should like, Ave put the little patient on tincture of Asclepias 5'- to water 5iv., a teaspoonful every hour, Avhich, with a hot mustard foot-bath, Avill soon establish secretion freun the skin. More frequently Ave Avill Avant to stimulate the action of the kielueys, as being the most important excretory or<>an. For this purpose I prefer a solution of acetate of potash. 154 DISEASES OF CHILDREN. Secretion from the bowels should be obtained by minute de)scs of Podophyllin, as named in the first part of this Avork, or other laxative. Or, if there is simply retention of feces, it maybe overcome by the use of mild laxatives or enemata. Purgatives should not be used unless there is a special indication for their employment. The fourth indication of cure is accomplished in the strictly malarial cases, by the administration of quinine in doses of one to two grains every tAvo hours, given Avith an acid. I never give quinine to chilel or adult until I have so prepared the system for its reception that it Avill act kindly, and as a curative agent. AVith the action of the sedatives, and secretion beginning to be established, it may be given Avith a considerable degree of cer- tainty. AVith the subsidence of the disease, and the establishment of convalescence, but little medicine Avill be required. I think it advisable to give the sedatives in quite small deises, for tAvo or three days after the fever has entirely passed away, as the child convalesces more rapidly under their influence. In some cases, a restorative aiels recovery. Elixir of Guarana, gtt. x. four times daily, or Comp. Spirits of LaATender, ansAvers a very good purpose. Or in some cases, dilute muriatic acid 5ij- to simple syrup 5ij., half a teaspoonful in Avater as a drink, every three or four hours, Avill ansAver a good purpose. Determination of blood to the brain is arrested by the adminis- tration of Gelseminum, Avhich, in this respect, is specific in its action. I usually giA7e it in combination Avith the sedatives, pre- ferring, when the fever runs high, to dispense Avith the Aconite, and increase the quantity of the Veratrum. In the majority of cases, ten drops to the four-ounce mixture, is sufficient. But when the determination is active, and likely to progress to in- flammation, I prescribe tAventy drops to four ounces of Avater. When there is danger of convulsions from the same cause, Gel- seminum may be relied on with great certainty to prevent it. The dull, congested condition, Avith tendency te> coma, is an- tagonized by the administration of Belladonna, Avhich is also specific in its action. I generally prescribe it with Aconite, in the following proportion : R; Tincture of Aconite, Tincture of Belladonna, aa. gtt. v., Avater 5iv.; a teaspoonful everv hour. The hot stimulant foot-bath, and occasionally counter-irritation to the spine, will be beneficial. But the dry rubbing, in both REMITTENT FEVER. 155 mild and severe cases, will frequently be all that is desired. It arouses the inactive condition of the system, restores the capillary circulation, and with the internal use of Belladonna, the cure is complete. The rubbing or dry bathing must be done gentlv but thoroughly, five minutes being sufficient time to operate, repeat- ing it every hour and a half or two hours, the hand movements being from the base of the brain down to the sacrum, the arms, thorax and abdomen operated on in the same manner. I have removed the congestion in very severe cases with no other remedies than these. The Belladonna wants to be given in small doses. Children being very susceptible to its influence, from gtt. iv. to viii. added to half a glass of Avater, and given in teaspoonful doses every half hour will give excellent results. The irritation of the stomach is met by the use of cold or warm applications to the epigastrium, and heat and stimulants to the extremities as the external means. Internally, Nux or Ipecac may be given, and they will do the work best "if given with as little fluid as possible. To accomplish this the preparation of Nux should be made stronger than usual, about gtt. v. to the ounce of water, and give gtt. xv. every half hour. Ipecac will operate charmingly in severe cases, if given in doses varying from one-tenth to one-sixth of a grain according to age of chilel. If there is nausea with flatulence, Colocynth alternated with the Ipecac will be the remedy ; or subnitrate of bismuth, in mint water. These are continued until the irritation is removed. At the same time, small doses of Aconite may be given for its seda- tive effect, and also for its influence in controlling the irritation of the solar plexus of nerves, Avhich attends the gastric irritation. Much care will be required in these cases, to prevent a renewal of the gastric irritation, as the disease progresses, especially to g'iATe our remeelies in such way that they will not be likely to produce it. In the second case, Avith atony and morbid accumulations, if the symptoms are marked, the shortest method Avill be to giA'e a prompt emetic. This is not a pleasant means with children ; but when the symptoms are grave, it is the most successful method. In malarial localities the emetic is usually a first consideration, as it is worse than useless to give the child other remedies until the stomach has been placed in a condition to reeeiVe them. The acetous emetic tincture or an infusion of gentian-root is preferable to use. In the same cases it w ill be absolutely essen- 156 DISEASES OF CHILDREN. tial to use : R> Podophyllin gr. 1-20, Leptandrin gr. 1-15, sugar of milk sufficient to make one grain of the powder. Dose, one every three hours during the first day, and three, one at morning, noon and night, during the second day. In other cases, sulphite of soda in five grain doses, may be administered every two or three hours, or if the tongue is red anel dirty, sulphurous acid. As a general rule, disease of the respiratory organs Avill yield readily to the treatment for the fever. If an inflammation is developed, I advise the mush-jacket to the chest. And if there is much cough, some simple remedy to relieve this. Rj Cam- phorated Tincture of Opium, Syrup of Lobelia aa: 5ss., Simple Syrup Siii. M. Dose from x. to xx. gtt. three or four times a day. Or, R; Chlorate of Potassa 5ss., Tinct. Aconite gtt. x., Tinct. Opium 5ss., Simple Syrup giv- M., and give a teaspoonful four times a day. SLOW INFANTILE REMITTENT FEVER. This disease is not only sIoav in its progress, but also obscure in its symptoms, so that many times it is very difficult to make a correct diagnosis. As before remarked, more or less of the symptoms of fever are Avanting, and others are quite irregular. Causes.—In a part of the cases that come uneler our notice, the cause is undoubtedly the malarial poison that produces other forms of periodic disease. This may be taken for granted, ay hen it occurs in a malarial region, or if the child has been exposed to this cause, liOAvever temporarily. In other cases, the disease is produced by derangement of the digestive organs, by imperfect nutrition and Avaste, by deficient excretion, and indeed by any of the many causes of diseased action. Pathology.—As with the other fevers, this must also be re- garded as primarily a disease of the blood, but as it advances, all the functions are impaired, anel there is also a continued deterio- ration of tissue. An arrest of nutrition is a prominent feature, so that Avaste continuing, the child becomes very much reduced in flesh. There are no special evidences of diseased action, found upon post-mortem examination, unless there has been some local com- REMITTENT FEVER. 157 plication, which generally manifests itself during life, by Avell pronounced symptoms. Symptoms.—Fe>r a Aveek or tAvo the mother notices that the child is not so Avell as usual. Its appetite is variable, its temper capricious, is fretful and irritable, is sometimes dull, Avants to sleep at unusual times, but does not sleep easily or Avell at regu- lar times, is restless and uneasy at night, tossing about in the bed, and wants to drink frequently. These symptoms slowly in- crease, anel the parents finding it is not the temporary ailment, from colel or teething that they supposed, call a physician. He hears the history of the case as above, and an examination confirms the symptoms. He also fiiuls that the pulse is not natural, but has a sharper beat, is a little more frequent, and has an unusual hardness in some cases, is softer and more easily com- pressed in others. The tongue sIioavs evidence of disease in its change of form anel its coating. In a feAV cases it is contracted, and presents a dusky redness, and the coating, if any, has a shade of brown. In the larger number of cases it is more or less pallid, frequently broader anel seemingly larger than common; in both cases the coating is a dirty or yellewish Avhite. The bowels are irregular, and the feces unnatural. In some, the feces are dark-colored, brownish, or greenish, in state of effer- vescence, and have a peculiar fetor. This is more frequent with the dusky red tongue, anel is generally said to indicate acidity of the primce vice; Avhether this is so or not, it is best remedied by the administration of an acid. In other cases the feces are light- colored, papescent, anel have not the natural feculant odor. The skin is dry, and in bad cases gives a parchment-like sensa- tion to the hand. Frequently, the extremities are cold, and in some cases the temperature of the child is lower for a consielera- ble portion of the day. The urine, if it be observed, will usually be found free, pale, and of Ioav specific gravity, although the waste of tissue is going on rapidly. In some cases it is highly colored, stains the clothes, and possesses in an eminent degree, the urinous odor. At some period of the day, slight febrile symptoms are devel- oped, and continue for one or two- hours. But they are ne>t very Avell marked, anel frequently escape notice. As soon, however, as the attention is drawn to it, the periodicity of the disease Avill be noticed. 158 DISEASES OF CHILDREN. Continuing on thus for Aveeks, the child becomes much reduced in flesh, and it no longer has the strength to sit up, or make an effort at play. Finally, if not arrested, or it is not naturally removed, some local complication is set up, Avhich runs an acute course, and causes a fatal termination. Diagnosis.—The diagnosis of slow infantile remittent fever is made by exclusion. The evidences of disease are very marked, but what the disease is, is obscure. The patient is examined Avith reference to local lesions. Is there disease of the brain or nervous system, of the digestive organs, of the respiratory sys- tem, or of the excretory organs? AVe determine there is not. It is then a disease of the blood, and a lesion of nutrition anel Avaste, and the symptoms observed will readily determine its periodicity. Prognosis.—The prognosis is favorable if the disease is diag- nosed, and a proper treatment adopted. But in its advanced stages it will not bear a harsh or very active treatment, but, on the contrary, requires time and patience. The vitality of the patient is so exhausted, and the functions are so impaired, that they require gentle and judicious stimulation to obtain the de- sired action. Treatment.—I place the patient upon the use of Aconite alone, if the pulse is soft and feeble, giving it in the usual doses. If the pulse is hard, I associate Veratrum with it in the propor- tions already named. I regard the action of the sedatives as very important in these cases, improving the circulation, both as to frequency, freedom, and an equal distribution of blood. No disease will better illustrate the fact that these remedies called sedatives, are really stimulant and tonic to the heart and blood- vessels. The sedatives are continued for one, tAvo, or three days alone, or with but little other medicine, and aided by the general bath and hot foot bath. A salt-water bath answers a very good pur- pose to stimulate the surface. AVe find that the circulation he- comes better, the skin less dry, boAvels more regular, innervation better, indeed, that every function has improved slightly under their use. If there has been marked dullness and hebetude of the ner- vous system, the combination of Belladonna and Aconite should remittent fever. 159 be employed. If there is irritation of the nervous system, Gel- seminum, or Rhus, as indicated, should be substituted. These means of meeting special indications, should not be neglected. With the influence upon the system named above, we may give remedies to call the excretory organs into action, if it seems necessary. The administration of small doses of Podophyllin, triturated as heretofore named, with one-fourth or one-half a grain of Sulphate of Hydrastia, three or four times a day, in- creases secretion from the intestinal canal, and improves the ap- petite. Acetate of potash, to the extent often grains daily, Avill give free excretion by way of the kidneys. Whether Ave use these means to increase secretion or not, Ave find a very important aid to the cure in quinine. I consider the patient prepared for its administration Avhenever the pulse be- comes soft, the skin soft and moist, and the tongue moist and cleaning. Usually, I give from tAvo to three grains at one dose, and afterAvard repeat it, one grain each day, for three or four days, or may be a Aveek. When quinine by mouth is objected to, or there is any other reason for not giving it in this Avay, I use it by inunction. I am satisfied that in some cases this use is decidedly preferable to the other, being more certain, as Avell as pleasant. I have the child thoroughly rubbed once or tAvice a day Avith an ointment of one drachm of quinine to tAvo ounces of lard. In some cases Ave find the tongue broad, pale, and covered Avith a pasty coat. If these symptoms are very marked, the mouth being nasty, and the breath fetid, I think the speediest method is the administration of a thorough emetic, and its repe- tition if necessary. In place of this I giA-e the sulphite of soda in the usual doses, repeated every tAvo hours. Rhus, Belladonna, Gelseminum, Apis, Arsenicum, and other remedies, will find a place in this disease according to indications. When the mucous membranes present the dark-red or dusky appearance, a very marked effect folloAVS the use of muriatic acid. Some very persistent cases, that haA^e been intractable to the ordinary method, will yield readily to the same treatment with the aciel addition. As a general rule, when the disease is soon arrested in its course, convalescence is steady, and tolerably rapid. AVhere it is not, Ave may put the patient upon the restoratives named in the treatment of the preceding form of fewer. 160 DISEASES of children. CONGESTIVE FEVER. There is a form of fever in childhood that may be properly called congestive, resembling in many of its symptoms the con- gestive remittent fever of the adult. It might have been passed by Avith the brief notice given in remittent fever, complicated with congestion of the brain ; but it Avould leave the student of medicine at a loss, Avhen he avus called to cases which, though distinctly febrile, presented the predominant symptoms of con- gestion. Pathology.—The causes of this may be the same as produce any form of fever; the congestive character of the disease de- pending upon the condition of the patient, rather than the causes of the disease. In the majority of cases, hoAvever, there is some- thing in the cause which seems to paralyze the vegetative or sym- pathetic nerves, and Avhich occasions the congestion. In some seasons, and in some localities, we find a tendency to this form of disease. Post-mortem examination evidences the local engorgements of blood, in discoloration, and transudation. In the severer cases, the blood is more broken doAvn, and the tissues more softened, than in ordinary fevers. Symptoms.—As a general rule the chill is protracted and better marked than in the fevers described. Indeed, in some cases it will last the greater part of the tAventy-four hours, not presenting so much a coldness as a dullness and hebetude. As the febrile reaction comes up, the child is not excited, but sleeps or dozes Avith its eyes partly open, and a full and expres- sionless appearance of the fae:e. This continues until the fever commences to decline, Avhen the chilel arouses up and seems more lively and better. This condition of the nervous system con- tinues throughout the disease, gradually increasing as the fever becomes more intense, becoming a profound coma in the severer, and especially in the fatal cases. The pulse is full and someAvhat labored, or in some cases the casual observer AArould notice but little change from its normal state, beyond its frequency. There is distinct evidence of an impaired capillary circulation, in the fullness of loosely connected tissues anel the dusky redness or lividity. The circulation be- comes more free during the remission, and the symptoms of con- gcstion pass aAvr.y. CONGESTIVE FEVER. 161 I have noticed the lesion of the nervous system, Avhich is so constant as to be a part e>f almost every fever. But there are also local congestions, Avhich become very marked. The respiratory apparatus suffers in this way in many cases. It is noticed that the child has a slight cough, attended with stime difficulty in breathing, and occasionally removing a frothy mucus. In a few hours the breathing becomes labored, there is a marked rattling or blowing sound in the chest. The cough fails to raise anything, though it is evident there is increased secretion, anel the evidences of imperfect aeration of the blood become Avell marked. Continuing 0:1 in this Avay, Ave find all the symptoms increasing rapidly, and sometimes death Avill ensue in twenty- four to feirty-eight hours. In other cases there is evident congestion of the abdominal viscera, and arrested functiem of stomach, liver, intestinal canal, etc. The symptoms are not so distinct as in the preceding case; yet the prostration of the little patient, the fullness and evident uneasiness in this region, are pretty good evidence. Add to this that the respiratory function is oppressed, anel the breathing principally thoracic, with an absence of the physical signs of elisease of the lungs, and the diagnosis becomes quite plain. Congestion of the kidneys is announced by a rapiel increase of coma, attended by a scanty or arrested secretion of urine. Diagnosis—There is usually but little difficulty in making the diagnosis of this disease. The evident impairment of the circulation is manifested by the pulse, and by the appearance of the patient. The dullness anel hebetude, and the development of ce>ma, are very characteristic. The local lesions are very readily determined, as named al)OATe. Prognosis.—If not properly treated, the prognosis is not so favorable as in other forms of fever. It frequently runs its course to a fatal termination by the fourth or fifth day. But if attention is given to this feature of the disease at the commence- ment, Avith our special remedies, the mortality Avill be but little greater than in other forms of fever. Treatment.—There are two methods of overcoming this con- gestive condition, both of them good, though differing entirely in their character anel mode of action. The first of these methods is by active emesis, the second by the specific action of Belladonna. 11 162 diseases of children. There are some cases in Avhich I should prefer the employment of an emetic. In a case Avhere the symptoms of congestion had eleveloped rapidly, and especially where there Avas marked coma, the action of the emetic would be the most speedy, and probably the most certain. The acetous emetic tincture is the best emetic in such cases, being very thorough in its action, anel also giving the stimulant influence upon the circulation. I ad- minister it in doses of gtt. x. to xx. every ten minutes, Avith some stimulant or aromatic infusion, and continue to repeat it until very thorough emesis is induced, and a free circulation of blood follows. The nervous prostration and coma are usually overcome by this action, and in many cases, after such thorough emetic, the disease will run the usual course of a simple remittent fever. Should the symptoms of congestion return, the emetic may be repeated every day, or even tAvice daily. In these severe cases I like the action of the hot blanket pack, as an adjuvant to the other treatment. To a kettle of hot water add an ounce of mustard, wring a blanket out of it, and wrap the child up in it, placing it in bed, and coATering warmly. In half an hour the Avet blanket may be replaced by a hot dry one, in which the child can remain until the means employed are successful. Another very efficient means of revulsion is—heat three, four, or five bricks on the fire until they are hot enough to vaporize water, yet not to burn the clothing; wrap them in cloths Avrung out of equal parts of vinegar and Avater, and place them at the feet, legs and body e)f the child, covering the whole looseely with a blanket, which should be well tucked in at the feet and around the child's shoulders, to prevent the escape of the vapor. It is very efficient as described, but may be rendered more poAverful by the addition of tincture of Capsicum to the vinegar and water in which the cloths are Avet. The above may be called the indirect method of treatment, and, as Avill be seen, requires considerable skill, and much attention from the nurse. For, Avhen improperly used, it may do as much harm as it would do good if used rightly. The direct method is Avholly different, but to persons in the habit of active medication Avill hardly seem sufficient for the purpose. The remedy with A\diich I propose to overcome the congestion, is Belladonna, in small doses. I generally administer it with Aconite. Rj Tinct. Aconite, Tinct. Belladonna, aa. gtt. v., Avater §iv.; a teaspoonful every hour. Had I not seen the congestive fever. 163 specific action of Belladonna in such cases so frequently, I Avould not be willing t) give it this recommendation. But if my ex- perience is to be depended upon, the remedy is most reliable, anel Avill give entire satisfaction. In this connection a very important part of the treatment Avill be stimulants and restoratives, and I shall refer to Elixir of Guarana, Comp. Spirits of Lavender and beef essence. They have filled the requirements so often that I consider them indis- pensable in these prostrating diseases. Usually, in these cases, I continue the same remedies through- out the treatment, as there is still some tendency to congestion or feebleness of the capillary circulation, especially of the brain. In congestion of the respiratory apparatus, in addition to the means named, or Avhen it is a special lesion, other parts not suf- fering so much, I depend principally upon small doses of Lobelia internally. For a c'lild three to six months of age Ave mav prescribe: Py Tinct. of Lobelia (seed) 5j-, Compound Tinct. of Lavender oij-, Simple Syrup Sij. Dose, half teaspoonful every fifteen minutes or half hour. For the local application I direct a cloth, sufficiently large to cover the anterior surface of the thorax, spread with lard anel dusteel Avith Comp. Powder of Lobelia and Capsicum. This is changed once or twice daily until the complication is removed. In congestion of the abdominal viscera I order hot stimulant fomentations to the bowels, occasionally preceded by dry cupping if the child is of some age, and an enema of an infusion of Bay- berry, to Avhich is added one drachm of tincture of Lobelia. The enema as named, is of especial importance in tho-se severe cases in which the danger is imminent and speedy relief essential. In congestion of the kidneys I apply hot fomentations across the loin.s, sometimes preceded by dry cups, and move the boAvels freely by the use of an enema of Comp. Powder of Jalap and Senna. In those cases in which there is a constant tendency to congestion of these organs, but in Avhich the urine is not sup- pressed to any considerable extent, Santonine, gr. one-sixth to one-fourth every three hours, Avill prove effectual. In all other respects the fever should be treated in the same manner as named for infantile remittent. In those cases in which the abdominal organs are principally affected, the sulphate of quinia combined with Avarm oliA'e oil, anel the abdominal organs thoroughly bathed Avith it and rubbed gently three or four times 164 diseases of children. daily, will give prompt relief. Te>o much importance can not be attached to this kneading and friction process, it supplies a long needed want in medical treatment, particularly in congestiem and some enher diseases, as marked beneficial results, after re- peated trials in practice, have proven. In those cases where an acid is required, I Avould always combine the quinia with it, adding aromatic elixir to form a pleasant preparation. The sul- phite of soda Avill also pnwe a very important remedy in some of these cases—the tongue presenting that peculiar broad, pale, pasty condition, heretofore named as indicating it. CONTINUED FEVER. As heretore noticed, continued fever is not of frequent occur- rence in early life; and, up to the fifth year, the common fevers of children are those already described. Indeed, Avith but ex- ceptional cases, Ave will not meet Avith continued fever, except in those years in Avhich it is the prevailing disease of the adult, being endemic or epidemic. At such times the cause of con- tinued fever is very intense, anel influences the child as Avell as the adult. A continued fever is never sthenic in childhood In the majority of cases it will present the symptoms of synochoid, or common continued fever, and only Avhen the cause of typhoid fever is intense, do Ave have this form of the disease Avith the intestinal complication. Typhoid symptoms, i. e., the evidences of de- pression and sepsis of the blood, is, however, of tolerably fre- quent occurrence. Causes.—AVe accept the usual theory, that this class of fevers is caused by an animal poison, or malaria. AVhat it is exactly Ave do not know, but that animal matter in certain states of de- composition Avill produce fever of this kind, is very clearlv proven. The fever poison may be generated by decaying animal matter, or by a person suffering from such disease, and being introduced into the circulation through the lungs, or the ordinary methods of absorption, sets up a process of change which gives us the phenomena of fever. Pathology.—As just stated, ths cause of continued fever is an organized body undergoing decomposition. It may be per- ceptible to the senses, or it may be in gaseous form, but it pos- CONTINUED FEVER. 165 sesses the property of setting up a like change in any material that possesses its elements with Avhich it may come in contact. The theory of Liebig is, that the fever poison resembles yeast in this respect, and that it not only sets up a process of decom- position in the blood, but develops a material similar to itself out of its elements. The evidence of this action is so marked and so Avell known that it is not ne>w a matter of controversy. The feA^er poison pe)ssesses varying degrees of intensity, just as yeast is Avcak and active. Like this, also, it possesses the poAver of setting up these changes in minute as Avell as in large quantity. AVhen the fever poison is active Ave find it producing fever of a gra\7e character, which either runs its cemrse rapidly to a fatal termination, or is prolonged and attended with great prostration. On the contrary, Avhen the fever poison is mild, the fever, though it may be protracted, is not of a grave character. These fevers are characterized by the length of their forming stage, or period of incubation. During this time the fever poi- son is insidiously undermining the powers of life. Digestion is influenced by it, as is assimilation anel the formation of blood. Every molecule that is formed into tissue during this period, re- ceives the impress of the poison in an imperfect development; and it is not until the patient is divested of all these imperfect tissues that real convalescence commences. Post-mortem examination reveals the same lesions that are found in the adult. There is marked change in the blood, both of the albumen, fibrin, and red globules. It does not coagulate firmlv, does not change readily Avhen bnmght in contact Avith oxygen, and the microscope shows the red globules more or less broken down. There is no special lesion of structure, except in those cases in which the glands of Peyer are involved, and these have presented the characteristic symptoms of typhoid fever during life. Symptoms.—One of the most marked features of a continued fever, is the long duration of the forming stage, which frequently embraces from one to three weeks. During this time the child Avill be dull, uneasy and fretful at times, will sleep more during the day, and will be restless and wakeful at night. Its appetite will be impaired, the boAvels irregular, and the skin dryer than usual. The tissues become soft and flaccid, and it loses strength in a marked degree. 166 DISEASES of children. The chill is usually protracted. In many cases an entire day, sometimes, indeed, tAvo days will be occupied Avith alternate slight chills and febrile exacerbations, SloAvly the fever becomes estab- lished, and, to the orelinary observer, it does not seem so severe as in the simple febricula, or infantile remittent, but the experi- enced practitioner sees in the prostration of the nervous system, the feeble circulation of the blood, the parchment-like skin, and the marked debility, evielences of a grave lesion. Day by day, as the fever advances, the strength becomes more impaired; the pulse is more frequent, is smaller and harder, or more frequently soft and easily compressed ; the skin is dry and harsh, and manifestly inactive; the urine is tolerably free, but is pale, frothy, and has an unpleasant odor ; the stools are also fre- quently papescent, and have an unpleasant odor ; the nervous system is markedly implicated. In some cases the patient is Arery restless and irritable, the eyes bright and the pupils dilated ; but in the majority the patient is dull, the face is expressionless, the eyes dull, and the child dozes Avith its eyes half open. Passing on toAvard the eighth or the tenth day, we notice that the child's mind Avanders, though there is never the manifest delirium that Ave Avitness in the adult. In other cases the dull- ness has passed into coma, Avhich gradually deepens until it ter- minates the life of the patient. The tongue shenvs distinctly the character of the disease. In a majority e)f cases it is contracted, its movement is impaired, and the coating upon it has a tinge of brown. In this case the tongue and mucous membrane of the mouth are of a dull-red or dusky hue, which once observed will ahvays convey to the mind the evidence of depravation of the blood. In a much smaller number of cases, the tongue is broad and pale, and covereel with a pasty white coat. In the first case, as the disease advances, the tongue becomes dryer, less mobile, fissured, and the coating of a deeper brown, until finally, in the severer cases, it is dry, black, and fissured, can not be protruded or hardly moved in the mouth, and bleeds when it comes in contact with anything, or even when movement is attempted. I am of the opinion that this condition is due rather to the harsh medication so frequently adopted, than to the disease. When the symptoms above are most marked, the passages of the nose and the throat are also involved, and in consequence continued fever. 167 there is a dry whistling respiration, sometimes with much diffi- culty. The lips also are dry, fissured, bleed, and form dark un- pleasant-looking crusts. The symptoms of typhoid fever have the addition of the intes- tinal lesion. Early in the disease the bowels become lax, which by the fourth or fifth day is a marked dirrrhoea; there is also the evidence of pain in the bowels, anel tenderness on pressure. A peculiar pinched appearance of the face is frequently seen, and may almost be regarded as pathognomonic of this condition. As the disease advances the intestinal complication is the most marked feature. The diarrhoea is very intractable, with evident pain and uneasiness before the evacuations. The dis- charges present an unpleasant appearance and an unusual fetor. Occasionally there is tympanitis. The natural duratiem of the disease is from three to four Aveeks, though in some cases it may terminate fatally by the end of the first Aveek, and by appropriate treatment it may be aborted in the early part of its course. During this period it may' be com- plicated with local diseases, as named under the head of infantile remittent, but as they present very nearly the same symptoms, and possess the same pathological character, they need not be further described. Diagnosis.—AVe determine the character of this fever, first, by the long duration of its forming stage, and the nervous pros- tration at the period of chill and commencement of febrile reac- tion. As it progresses, the continued febrile reaction, Avithout remission, gives it a distinctive character. The typhoid form of continued fever is diagimsed by the ap- pearance of diarrhoea early in the disease, Avith tenderness on pressure about the umbilicus, and evident intestinal uneasiness, if not pain. In these cases, alse>, the fever is of an asthenic type, and there is especial prostration of the nervous system. Prognosis.—The prognosis is not unfavorable if the disease is properly treated; but under the old antiphlogistic treatment the mortality Avas sometimes large. Indeed, if patients are care- fully nursed, and have proper food, the disease being alhnved te> run its regular course, the mortality will not be more than ten per cent. Treatment.—The object of treatment in this disease is tAvo- fold—to shorten its duration, and relieve unpleasant symptoms. 168 diseases of children. In some feAV cases Ave may safe? life, but they must be few, as the mortality is but small, anel semie of the deaths are unavoidable, as the disease involves all the tissues of the body, which mu.-t be removed before convalescence is completely established. AVith simple functional lesion we might expect te> arrest the disease at once; but Ave are doing well to accomplish it by the seventh to the ninth, or sometimes the tAventy-first day. As heretofore named, the first indication of cure is to correct the functional disturbance, fen* this must precede the removal e>f structural lesions. The derangement of the circulation of blooel is manifestly first in order, and if Ave can correct it, other indica- tions of treatment will be readily accomplished. I prescribe in thiscase,as in other fevers, the special sedatives, as: R> Tinct. Aconite, or Tinct. Veratrum, gtt. v., Avater Siv., a teaspoonful every hour. This is continued to the complete establishment of coiwalescence, AvhateA'er additional means may be employed. If there is irritation of the nervous system, Avith flushed face, restlessness, sleeplessness, and other evidences of determination of blood, Ave give Gelseminum in combination Avith the sedatives ; but if on the contrary there is dullness and hebetude, the patient being elrowsy, sleeping Avith the eyes part open, and as the dis- ease progresses tending to coma, Ave use Belladonna instead, as: R> Tinct. of1 Belladonna, Tinct. of Aconite, aa. gtt. \\, Avater Siv., a teaspoonful every hour. The patient has a sponge bath once or tAvice daily, ahvays used carefully so that the surface will not be chilled. Sometimes Ave finel it better not te> employ the bath after the first tAvo or three days, on account of the prostration that folloAVs. The hot foot- bath is both an aid to the action of the sedatives, anel valuable to relieve irritation of the nervous system and produce sleep. When there is great Avakefulness Ave render it more stimulant by the addition of mustard or capsicum. There are some cases, though in most seasons but feAV, in Avhich decided benefit Avill fedlow the use of an emetic in the early stage of the disease; indeed, occasionally it offers the only safe cenirse. The cases are those in which the tongue is broad, covereel with a heavy yelloAvish white fur, especially at its base. The breath is frequently fetid ; there is nausea and retching, and medicines are rejee-ted by vomiting, or, if retained, are not absorbed. In such cases deterioration of the blood goes on remittent fever. Igg rapidly, and typhoid symptoms are developed early. A thorough emetic of acetous emetic tincture, or Ipecacuanha, removes ac- cumulations from the stomach, stimulates it to better action and prepares the way fe>r the successful administration of other remedies, anel the digestion of food. There is yet another condition in Avhich an emetic can be em- ployed with marked advantage. I allude to those cases in which there is marked nervous prostration, Avith dull eyes, expression- less countenance, tendency to sleep, Avhich Avill soem pass into coma. In these cases the action of the emetic arouses the nerv- ous system, and at the same time gives a better and more equal circulation of blood. When the tongue is pallid, usually with a whitish pasty coat, I like the action of the alkaline sulphites. The sulphite, or hyposulphite of soda is in most common use, anel mav be given in doses of five grains every three hours to a child tAvo years old. It may be commenced at the beginning of the treatment, and used with the special sedatives. It is discontinued when the condition for Avhich it has been given is removed. Frequently a day will make such a difference in the patient, especially after the remedy has been given for three or four Jdays, that Ave Avill finel it necessary to put the patient upon the use e>f an aciel. When the mucous membranes are dark-reel, or dusky, the tongue being in a majority of cases dry anel contracted (occasion- ally it is moist), I give the muriatic aciel from the commencement of the treatment, using the fen-mula heretofe>re given: R Dilute Muriatic Acid, oij., Simple Syrup, 5ij. Adel it to AA'ater so as to make it pleasantly acid, and give as a drink. The chilel can hardly take too much ; usually about one teaspoonful of the mixture every tAvo hours Avill be the proper quantity. There are some cases in Avhich irritation of the stomach, Avill be an unpleasant feature in the early part of the disease. Not only so, but it Avill aggravate all the symptoms, prevent the action of remedies, and* cause the disease to run a more rapid course, and increase its fatality. This irritation should be arrested early. So important is this, that it will take precedence of all other treatment. I generally prescribe a colel application—cloths wrung out of colel Avater, or its opposite—hot fomentations applied over the Avhole abdomen. An infusion of the bark of the young limbs of the peach-tree, in small doses, is very efficient in quieting this irritation. In other 170 diseases of children. cases, the subnitrate of bismuth, in mint Avater, may be employed. An infusion of the compound poAvder of rhubarb, given in small doses, has ansAvered a gewd purpose, sometimes continuing the remedy until it produces a slight laxative effect. In this case, Aconite alone of the sedatives may be used, with the addition of Gelseminum, if there is irritation of the nerve- centers, or Ipecac if there is intestinal irritation. The dose is five drops of the Aconite to four ounces of Avater. Cathartics are not employed in this fever, unless there are special indications for their use. This woulel be, evident accu- mulations in the intestinal canal, and irritation from this cause. The usual evidence from the tongue, is its uniform yellowish coat, extending from base to tip. AVith the means already named, judiciously selected to meet the indications of the case, Ave find the patient progressing favor- ably. The disease yields, day by day—the pulse becomes less frequent, but is greater in volume and in freedom of circulation— the irritation or depression of the nervous system passes aAvay, and the secretions are gradually established. In a majority of cases, no other medicines Avill be required, as Avith proper nursing and fooel all symptoms of febrile disturbance Avill have passed aAvay by the seventh to the fourteenth day. In a feAV cases Ave Avill find it necessary to stimulate secretion from the skin and kidneys, after the sedative has produced its effect. The Comp. Powder of Ipecac and Nitrate of Potash, will be found a gewd remedy for this purpose, and Avill also act very kindly on the nervous system, and promote rest and natural sleep. Occasionally Ave are called to take charge of cases of fever Avhich have run the first part of their course, and have some- times been aggravated by the medicines employed. All forms of fever will, if severe, or badly managed, present much the same lesions and symptoms; these being of an asthenic or typhoid type. In diagnosis, as Avell as in our therapeutics, Ave group them in four classes—with reference to the circulation—with reference to digestion and the formation of blood—Avith reference to the nervous system—and with reference to Avaste and excretion. The action of the heart is rapid, but imperfect, anel though the blood apparently moves faster, there is deficient circulation in the capillaries. Here small doses of the special sedatives exert a most marked influence. As the pulse becomes less fre- continued fever. 171 quent under their influence, the action of the heart is stronger and more regular, and the blood circulates more freely, and is more equally distributed. In the majority of these cases Ave prefer the use of Aconite, but are governed even in this ad- vanced stage by the rules already laid down. It is of very great importance to the success of treatment at this advanced stage, that the stomach be placed in condition to receive and digest small portions e>f food, for the real elanger is, many times, from starvation—a faiiure of vital power, from a Avantof nutrient material to sustain it. One of tAvo conditions Avill usually present—the tongue Avill be contracted, dry, fissured, and coated broAvn or black ; the lips, also, Avill be dry,, and occasionally covered with an unpleasant crust. The mucous membrane of the mouth, tongue, nose, etc., is dark-red or dusky. In this case, Ave administer dilute muri- atic aciel, as heretofore named, giving it as a drink, and as freely as the child chooses to take it. In the other case, the tongue is broad, pallid, anel moist, and covered Avith a pasty fur. Here we give sulphite of soda, in the usual doses. For the use of the anti-zymotics the reader is referred to page 95. To improve innervation, anel get its general influence upon the system, I like the action of quinine used by inunction. In- ternally, it is not kindly borne at this stage of the disease.- AVe find also, that this fatty inunction improves the condition of the skin, anel also increases the general vital power of the child. The fooel of the child will be boiled milk, with sufficient salt to make it pleasant. It is more kindly received and better di- gested, if taken quite Avarm, the heat acting as a stimulant to the stomach. Children take food, because they haATe an appetite or desire fe>r it, and, neit as the adult sick may, because their reason shows the necessity of it. In disease, Avhen there is no appetite, but on the contrary, disgust for fe>od, they can not sometimes be persuaeleel to take it in the usual manner of taking fooel. In such eases, instead of letting them suffer from the want of it, I have the milk given as a drink, eA'en sometimes mixed with one or two parts of Avater. The necessity of this attention to giving food should be forcibly impressed upon the mother. If the child Avill not take milk, Ave may have preparations of arroAv-root, sago, tapioca, maizena, etc., or occasionally a beef osseMioe* will answer a good purpose. A good way to make a beef tea for a child, or even an aelult, is as folloAvs: Cut a lean and 172 DISEASES OF CHILDREN. tender piece of beef in small pieces, rejecting all the fat; put in a tin or porcelain-lined vessel and cover with cold water; set on the stove and bring it sloAvly to the boiling point, letting it boil for half an hour. AVe thus get the elements of the beef in a fluid form, anel with the necessary salt it will be quite palatable. The attention to the skin, by the quinine inunction, or an occasional stimulant bath, with brisk friction, will be all that Ave can do to get secretion from this organ. As a general rule, it Avill not be good policy to stimulate the kidneys by special means, at this advanced stage of the disease. Occasionally, Avhen con- valescence is being established, Ave may administer a saline diuretic in small quantity, to facilitate the removal of Avaste. The tincture of muriate of iron, recommended to aid convalescence, strengthens and increases the action of the kidneys. As a gen- eral rule, the boAvels had better not be interfered with. But where there is irritation from accumulations in the intestinal canal, a gentle purgative of compound poAvder of rhubarb will ansAver a good purpose. In those cases in Avhich the tongue is broad and pale, minute doses of Podophyllin, triturated as here- tofore described, may be used with advantage. Occasionally Ave associate one-fourth to one-half grain of hydrastis with it. In some few cases, there is tarely passage of urine, or complete retention, and if this is not seen to, it Avill lead to a fatal termi- nation. The use of diuretics, as generally advised, is bad prac- tice. Instead, I prescribe santonine, triturated with sugar, in doses of one-sixth to one-fourth gr. every hour, until the patient is relieved. Its action in this respect is specific. In some other cases, the urine is suppressed, producing at first irritation of the nervous system, then coma, Avhich gradually deepens until the child dies. In other cases, convulsions ensue, and the patient dies of them. In this case, also, I do not depend upon diuretics. Instead, I have hot fomentations applied assidu- ously across the lions. Usually the fomentation is of vinegar anel water; but if there is evident congestion, it may be rendered stimulant. SPOTTED FEVER. Though not a disease of childhood exclusively, yet it has pre- vailed among children more than adults, and deserves considera- tion here. Indeed, if Ave were to reject all the diseases which attack the adult as well, Ave would have but a small list remaining. spotted fever. 173 Spotted fever has prevailed in this country to a very considera- ble extent since 1862. In some localities it seemed endemic, while in others it was decidedly epidemic. AVhether or not it is contagious has been in dispute; some contending that it is, others that it is not. My own opinion is that spotted fever is, in orelinary cases, contagious, like typhoid fever; that when very malignant, with marked symptoms of putresceney, a fever poison is evolveel which wi 11 affect persons avIio come in contact with it. There is, again, an epidemic form in Avhich the conta- gion is as marked as in typhus fever. Many have supposed that spotted fever Avas a neAV disease, bearing no relation to diseases known and described by authori- ties, and have been at a loss Iioav to treat it. The fact is the disease has appeared several times previously, and bears a very c!e>se relationship to typhus fever, with the addition of a sub- acute cerebro-spinal meningitis. This fever first made itsappearance in this country in the toAvn of Medway, Massaeihusetts, in the year 1806, and preArailed to a considerable extent in New England from that time up to 1815. At this time it presented the same symptoms, Avas as malignant, and attended by the same mortality. The same disease is noticeel by historians as having prevailed over the greater part of Europe in 1505, 1528, 155(5, and at vari- ous times up to 1805; and Ave can trace it under the names of hospital, jail, putr'd, or spotted fever, in almost all parts of the world during the last century, follenving in the train of the great European armies, among Avhich it made the most destruc- tive ravages, and by Avhom it Avas spread over the greater part of Europe. Cause.—The cause of spotted fever is undoubtedly an animal poison of very great activity, resembling in many respects the fever poison or malaria of typhus. AVe do not know definitely Iioav it was produced in this country ; yet in all previous epidem- ics it has been traced to crowding, bad ventilation, and especially to the decomposition of human excreta. Pathology.—In its pathology this fever does not differ very materially, save in its malignancy and rapidity, from that last considered The fever poison, Avhatever it may be, Avhen once introduced into the blooel, reproduces itself more or less rapidly, and finally causes the death of this fluid. In some cases the 174 DISEASES OF CHILDREN. virulence is such, that Avithin forty-eight or even tAventy-four hours, the blooel is completely broken down, dies even before the vital functions have ceased. Post mortem examination reA'eals a breaking doAvn of the blood in greater degree than in typhoid fever. There is also extravasation of blood, and especially of its coloring material, so that parts which were congested during life are much discolored, as are the most dependent parts of the body after death. Parts that have suffered from local congestion are also softened, some- times so much so that they may be readily separated and broken Avith the handle of the scalpel. The spleen is engorged Avith dark grumous and broken doAvn blood, and is frequently enlarged. The liver is also dark-colored, SAVollen, and friable. The lungs seem to have suffered in like manner, are filled with blood, and the bronchial tubes contain a dark-colored offensive mucus. The surface of the body presents in some cases a remarkably spotted or ecchymosed condition. The discolorations are purplish or almost black, and most numerous on the most dependent parts of the body. A close examination reveals that they are true ecchymoses or vibices. Symptoms.—The symptoms vary in different cases and in different localities, but may be divided into two prominent classes, as folioavs : First. For tAvo or three days the patient is listless, dull, and stupid, the face is flushed and dusky, eyes tumid, some pain in the head and back, loss e)f appetite, tongue dusky-red and coated with a dirty-white mucus, skin dry. This is the forming stage of the disease, and instead of lasting as long as named, Avill, in the severer cases, not be longer than tAventy-four hours. Following this there is a tolerably well-marked chill, lasting for tAvo or three hours, and attended Avith great pmstration. Febrile reaction follows, sometimes high, at others not very well marked. In the one case the surface becomes intensely hot and flushed, the pnlse 120 to 140 in the adult, and so that it can scarcely be counted in the child, sharp and hard, with great irri- tability and restlessness, though there is marked dullness of the intellectual functions. The thermometer marks a temperature in these cases of from 104 to 109 degrees. The urine is scanty and the boAvels constipated. Frequently there is difficult respi- ration, some cough, and sibilant rales. SPOTTED FEVER. 175 In from tAvo to six days an eruption appears upon the surface, very closely resembling measles, but more clearly defined. If the patient recovers they commence fading out by the end of the fi-rst twenty-four hours, but do not disappear entirely for some days. If the disease progresses unfavorably, they become dusky, and at last livid and associated with vibices. As their color be- comes darker the nervous system of the patient becomes more oppressed, his mind wanders; and, becoming livid, he sinks into a stupor from which he can not be aroused, and Avhich in a short time terminates in death. In the second case there is but little reaction, the pulse running up to 90 or 100 in the adult, 110 to 120 in the child, and op- pressed. There is tendency to coldness of the extremities, the skin being harsh and dry, or sometimes moist and atonic. The eruption appears the first, second, or third day, and is a dusky-red, not readily effaced by pressure. There is marked dullness and hebetude from the commencement, and frequently the patient is almost entirely unconscious a few hours after the appearance of the eruption. It runs a very rapid course in most instances, terminating fatally by the third to the sixth day. The eruption becomes dusky and livid, petechiae ap- pear, the tongue is dry and broAvn, sordes on the teeth, urine and faeces very offensive, coma or Ioav muttering delirium, and gradu- ally increasing difficulty of respiration. Diagnosis.—The diagnosis is not ahvays easily made at the commencement of the disease; yet this is not so important, be- cause the symptoms sIioav it to be a grave form of disease, of a congestive and malignant type. The extreme febrile reaction in the one case, associated as it is Avith dullness anel hebetude of the intellectual functions, the dusky discoloration of the tongue and mucous membrane of the mouth, are characteristic symptoms. In the other case, the great prostration, feeble reaction, dull- ness and tendency to coma, the appearance of the dusky erup- tion, etc., sIioav the nature of the disease. Prognosis.—The disease varies in malignancy and mortality in different sections of country and at different times. So that Avhile under one class of circumstances Ave s'muld regard the prognosis as favorable in a large majority of cases, in another it would be unfavorable. Much Avill depend upon the time when the patient is seen. If quite early in the progress of the disease, very severe cases may 176 diseases of children. be conducted to a favorable termination. AVhile, if the disease is alloAved to progress unchecked for a day or tAve), e>r is aggra- vated by injudicious medication, the more mild cases will be rendered unmanageable. Treatment.—There are three plans of treatment that I think may be relied upon, and I will state them plainly, endeavoring te> point out the special cases Avhere a preference should be given te> one over another. Taking the majority of cases I think I should value them in about the order in Avhich they are stated, relying upon the first plan especially in very bad cases. Make an infusion of Capsicum one part, Bay berry six parts, having it as strong as the patient can take it with comfort Them give the acetous emetic tincture in doses of from one-fourth to one-half teaspoonful every ten or fifteen minutes, with as much of the infusion as the child Avill drink. We do not wish fo pro- duce immediate vomiting, but desire to get the general influence of Lobelia upon the system, so that if it is not Avell federated by the stomach, we lessen the dose, and apply a stimulant femienta- tion over the epigastrium, to aid its retention. Continuing it in this way for one hour or more, we notice that the depression of the fever is being replaced by the influence of the Lobelia, anel when this becomes marked, Ave carry it to free and thorough emesis. In the meanwhile, the child being placed in bed between blankets, hot bricks Avrapped in flannel wrung out of an infusion of Capsicum Avith vinegar and Avater, are placed at the feet, by each thigh, and by each side of the trunk, at such distance as to be in no danger of burning the child. Have the blanket loose over the body, but well-tucked down at the feet anel around the neck, to prevent the escape of the vapor. After a free and vigorous circulation is established, the body may be rubbed dry with a flannel, and Avrapped in a dry blanket. In the second method of treatment Ave desire to obtain the stimulant influence of Lobelia or Ipecacuanha upon the circula- tion. I would order them in this fe>rm : Rj Lobelia Seed (powdered), gr. xx.; Capsicum 5j. Mix and divide in eighty powders. These may be administered as often as every fifteen minutes, every half hour, or hour. Occasionally they will pro- duce slight nausea, which is not objectionable, providing it does not go so far as retching or the rejection of the remedy. Ipecacu- anha is given in doses of one-fourth to one-half grain every hour, ahvays less than will produce vomiting, and is thus con- SPOTTED FEVER. 177 tinned until reaction is well established. I like the action of the Lobelia the best, though the Ipecac has been used with considera- ble success. To aid these, an enema of an infusion of Bayberrv, Lobelia and Capsicum, may be employed with good advantage. I am satisfied that I have seen the patient aroused by this means, so as to obtain the influence of other remedies by the stomach, when Avithout this, it would have been impossible. Dry cupping to the spine, is sometimes of advantage, but in the majority of cases, I would prefer the stimulant vapor-bath, as first named, and friction with Comp. Tinct. of Capsicum. The third method of treatment is based upon the specific action of Belladonna to overcome congestion and stimulate the circu- lation. This has not been as thoroughly tested as Ave Avould wish, yet some very favorable reports have been made e>f it. In Cali- fornia, the Atropia has been employed; Ave have ah\Tays used the the tincture of Belladonna. For a child two years old, I should order: Py Tinct. of Belladonna gtt. v. to x.; Tinct. of Aconite gtt. v.; Avater 5iv. Of this, give a teaspoonful every half hour, until its influence in arousing the nervous system anel overcom- ing the congestion is noticed, afterAvard every hour, until the circulation becomes free, and the dangerous symptoms have passed aAvay. In either case I should employ the sulphite of soda, or sul- phurous acid, in the usual doses, as soon as this first influence Avas established, and continue it until the dirty coat was entirely gone. But if at any time, the tongue becomes dry and dark, I Avouhl substitute the dilute muriatic acid. The Comp. PoAvder of Leptandrin may be given in from one to tAvo grain doses four times a day with remarkable efficacy. It acts mildly, but efficiently, upon the glandular system, anel re- mo\Tes morbid and Avorn-out material from the intestinal tract, leaving it free from irritation. Quinia may be used by inunction, early in the disease, and its use in this Avay continued to the complete establishment of con- valescence. I do not think that its internal administration in the early stages of this disease, has been attended Avith any good effect, but, on the contrary, has frequently increased the depres- sion of the nervous system. Tincture of muriate of iron may be occasionally given alter- nately Avith the sulphite of soda, so as to obtain the good influ- 12 178 diseases of children. ence of both. In a majority of cases, it will be well to put the patient upon its use for some days after other remedies are suspended. EPIDEMIC CEREBRO SPINM, MENINGITIS. Closely associated with spotted fever, and also with diphtheria, is the disease knoAvn by the name of epidemic cerebro-spinal meningitis. These three bear a very ckhse relationship, in that each presents very similar lesions of the nervous system, both during the progress of the disease, and in the sequelae. In all three there is the evidence of the action of a blood poison, and the breaking doAvn of the blood, and in each, death may be the result of the lesion of the nervous system, or of the lesion of the blood. In this country, Avithin the last ten years, the three diseases have prevailed in an epidemic form, one succeeding another, and in some cases seeming to merge into one another. AVe had first the epidemic diphtheria, next the epidemic spinal meningitis, and last the spotted fever. Pathology.—The profession are not agreed as to the path- ology of epidemic spinal meningitis, though it is now generally regarded as bearing a very close relation to typhus and typhoid fevers, epidemic dysentery, etc. I think there is no doubt but that it is produced by an animal poison, Avhich, gaining entrance to the blood, gives rise to the phenomena of fever, and acting from the blood, specially affects the cerebro-spinal centers, pro- ducing the peculiar lesions that characterize this disease. AVhat this poison is, Ave are unable to say, neither are Ave able to account for its origin or propagation, in many cases. That the disease is contagious, in its severer forms, I am Avell satisfied, but this is also true of typhoid, especially of typhus, and, at times, of nearly all diseases Avhich present that grouping of symp- toms called typhoid. In se>me instances, it has seemed as if there Avere an endemic influence causing the disease. In others, it has been distinctly epidemic. There is yet much mystery in regard to epidemic influences, anel until the subject has been more thor- oughly studied, it will be useless to theorize upon it. Symptoms.—The cases of cerebro-spinal meningitis may be divided into tAA'o classes, the distinction being very marked. cerebro-spinal meningitis. 179 Occasionally, Ave will find it prevailing in both forms, at the Eame time, in a locality ; but more frequently it will maintain the one form in all the cases, at one place, or during one season. AVe may call these tAvo classes the rapid and the slow cerebro- spinal meningitis, as this expresses the greatest difference in the symptoms. In the first, or rapid form of the disease, there is but a short period of incubation, rarely exceeding a day. The patient feels dull and prostrated, and if old enough to complain, it is of pains in the back, head anel limbs. The chill is usually Avell marked, the extremities being cold, the surface shrunken and pallid, anel occasionally, severe rigors. It will be noticed that during the chill there is greater dullness of the mind and prostration than should attend an orelinary chill, and the patient seems to suffer severely. In the course of one or tAvo hours, the chill passes aAvay and febrile reaction succeeds. The surface becomes flushed, and the temperature is increased. The pulse increases in frequency to 120 or 140 beats per minute. The face is flushed, the eyes in- jected and suffused, and the head is Avarmer than other portions e>f the body. The tongue and mucous membrane of the mouth are usually dusky, and the tongue coated Avith a yelloAvish-Avhite pasty fur. During "the first feAV hours, sometimes for a day, the patient complains of pain in the back, anel muscular pains in various parts of the body, and though there is great dullness of intellect, yet the patient is restless and uneasy. It will also be noticed that moving the child increases the suffering, sometimes so much that Ave are obliged to let it remain in the one position. By the second day, the patient has sunk into a stupor, from which it is difficult to arouse it. The surface is markedly flushed and dusky ; the pulse very frequent and wiry, in the majority of cases, but in some it is open but oppressed. Respiration is diffi- cult, and the patient shows marked evidences of imperfect aera- tion of the blood. The characteristic symptom is a fixure of the spinal column, the head being drawn backward, or to one side ; or the disease may show itself in the same way in the dorsal or lumbar regions. Occasionally, Ave notice evidence of partial paralysis this early in the disease. At other times, convulsions come on early, or the disease is announced by them. Thus it progresses rapidly to a fatal termination, the patient 180 diseases of children. rarely lasting longer than four or five days, if not relieved, anel sometimes it terminates fatally within forty-eight hours. In the other form of the disease, the forming stage may last from one day to a week, presenting the usual symptoms of dull- ness and hebetude, and arrested function. The chill is not very marked, though it may last for the greater part of a day, or be made up of slight chills and febrile-reactiems, of short duration. Reaction comes up slowly, and is not. fully established before the end of the first twenty-four hours. The temperature is increased, the pulse increased in frequency and hardness, the patient restless and fretful, and if old enough, complaining of pains in the back, head, limbs, or not unfrequently, simply of a hurting, Avithout being able to locate it at any one point. The secretions are arrested; the skin becomes dry and harsh, the urine scanty anel high colored, and the boAvels constipated. The tono-ue in some cases is contracted and reddened, with a coat having a shade of brown ; in others it is broad, pallid, and cov- ered Avith a pasty Avhite coat. Usually at first, the face is slightly flushed, the eyes bright, the pupils contracted, anel the mind active. The patient is uneasy and restless, and ehies not sleep well. The child maintains one position, and the fixure of the back is marked, and if moved, so as to bend the spinal column, it cries out with pain. Thus, day after day, the fever continues, sometimes' presenting the symptoms of a remittent, at others of a continued fever. There is a gradual increase in its severity, and necessarily an in- creasing debility of the child. Occasionally the feArer will run very high about the sixth to the tenth day, and there will be evident delirium. Passing into the third Aveek, the symptoms assume a typhoid condition, Avhich gradually increases as time passes. I do not think that at this time there are any distinctive symp- toms, but the tenderness on pressure over the spine, and the pain when the child is moved, except, possibly, the greater excitement of the nervous system, which in this case replaces the dullness of typhoid. But sooner or later in the disease, this excitement is replaced by coma, Avhich sometimes becomes a marked feature in fatal cases. A peculiarity of the disease is, that having run the course I have described, for tAvo, three or four Aveeks, the symptoms gradu- ally give Avay to treatment; the fever is arrested, secretion SPOTTED FEVER. 181 established, the child sleeps well at night, takes food and seem- ingly digests it, but further than this there is no advance to re- covery. There is no increase of the strength, indeed, no increase of flesh, anel thus week after week will pass by without an appre- ciable change. After a time, however, it will be noticed that the child is failing, and in two or three weeks it dies—but of what it is impossible to say. I have known of many cases that had a duration of three or four months, anel an exceptional case that terminated fatally at the commencement of the eighth month from the date of attack, there being no time during which the child Avas able to sit up. Diagnosis.—In the first form of the disease, the symptoms are of a very grave character from the commencement, anel v e are able to trace their relationship to spotted fever anel the more malignant cases of diphtheria. The pains in the back and head, the severe muscular pains, are characteristic, and even where the child is too young to describe its sufferings, its appearance Avill evidence it. The pain, or expression of suffering, upon moving the body, is the evidence of spinal disease. In the second class e>f cases, the disease comes on insidiously, and there may be but little, if anything, to arouse the suspicion of the practitioner that he has more than an ordinary fever to treat. But after aAvhile his attention is attracted to the pain when the chilel is nmved, and the greater irritability of the nerv- ous system and restlessness than is common in ordinary fevers. Prognosis.—I do not regard the prognosis as unfavorable if the disease is seen in time, and a proper treatment is adopted. Taking the disease as it ordinarily prevails, it is probable that the nmrtality will vary from ten to twenty per cent. AVe must not forget the fact that in some situations the cause of the disease is vrery intense, and it exhibits very great malignancy. Indeed, in some localities, many times, death would have commenced be- fore the physician was called to the patient. Treatment.—In the first form of this disease, I Avouhl strongly aelvise that the treatment be commenced with a thorough emetic, of some preparation e>f Lobelia. In this case as in spotted fever, Ave desire the general influence of Lobelia, as Avell as the act of emesis, or in other words, we Avant the act of emesis as the result of its general action. The acetous emetic of our 182 diseases of children. dispensatory, or the Comp. Powder of Lobelia and Capsicum, are good preparations for this purpose. Give in five to ten drops doses Avitii Avarm Avater, repeated every five or ten minutes, and Avhen the system is brought fully under the influence of the remedy, Avhich will be in one or tAvo hours, then more freely until emesis results. In many cases it will be necessary to folloAV emesis Avith a cathartic. This is particularly requisite in malarial localities. The intestinal tract is in the same morbid condition as the stomach, and must be aroused ere Ave can hope for a satisfactory response from our sedatives or other indicated remedies, Avhen quick action is desired. I like the action of Rhamnus P. best, prepared as folioavs : Rj Tinct. Rhamnus P. Sj., Tinct. Taraxicum 5j-, Simple Elixir 5J. M., and give from gtt. xv. to xxx. every two hours, until there has been good action. If sIoav action is desired we can use the Leptandria compound gr. ij. every two or three hours. Then comes our sedatives, Aconite or Veratrum, Avhichever is indicated ; Veratrum, if the patient has a full bound- ing pulse, and Aconite if it is small in volume and easily com- pressed. Of the former, gtt. x. to half a glass of Avater; of the latter, gtt. v. to water §iv. Marked cerebral irritation or coma will generally be present in a major portion of cases, and in the irritative ones, Rhus tox. is a prominent remedy ; given, a.case with excited circulation, frontal pain, prominence and redness of papillae, and tip of tongue, and Ave have the true indications fe>r the remedy. In these cases, then, Ave would think of Rhus and gi\re it curatively. We have another class of symptoms that pre- sent great vascular excitement, contracted tissues and pupils, face flushed, and extreme restlessness ; here Ave would substitute Gelse- minum for Rhus anel get its specific action ; gtt. v. of the Rhus to Avater oiv., and xv. of the Gelseminum to the same quantity of Avater, will be the right proportion ; give in teaspoonful doses every hour. In the opposite cases Ave have dullness and hebe- tude, patient sleeps Avith eyes partially unclosed, tissues are sodden and the whole system is in an atonic condition. From five to ten drops of Belladonna added to half a glass of Avater and given every half hour or hour, according to the severity to the case, will remove the congestion and leave the system in better condition for the action of other remedies. If there Avas large pulse, tongue broad Avith dirty coat, SAveetish taste in the mouth Avith pallor of mucous membranes, I should SPOTTED FEY'ER. 183 prescribe sulphite of soda, grains two to four every three hours ; but with deep redness of mucous membranes, slick tongue, anel typhoid symptoms, the patient wants muriatic acid. In such cases I should associate Baptisia with the acid In septic condi- tions they are definite agents and as such produce definite results. A\ ith the system prepared for the antiperiodic, Ave may give it either by mouth or by inunction. Where the soda is indicated I prefer giving the quinine by inunction. In the other cases I should give an acidulated elixir of quinine. Where there is a torpid circulation of the skin, I should associ- ate it with a stimulant, as follows : fy Quinia Sulphas 5j., Cap- sicum gr. x. to oss., Adeps 5ij.; mix thoroughly. This may be used with brisk friction tAvo or three times daily, and if the tem- perature of the extremities is lowered, apply dry heat or friction with the hand. In the second case, the treatment need not be so active. I am not certain, hoAvever, but that in many of these cases Ave might obtain much advantage from the action of the emetic in the first tAvo or three days. Indeed, I am satisfied that in tAvo cases I arrested the disease by this means. But Ave Avould think more particularly of Rhus and Macrotys, plus the required sedative, in these irritative cases, though even the sedative is not ahvays necessary, Rhus doing the work nicely. Indications for Gelseminum will be met with that remedy sub- stituted fen* Rhus If Ave get an indication for a certain remedy in a large number of cases, Ave then have an epidemic remedy, and with the seelative is all sufficient. Tavo or three remedies rightly chosen, have, in some of the severest types of disease of this character, always given me good results. The generat sponge-bath, sometimes Avith hot Avater, tAvo or three times a day, Avill be found an important aid. If the bowe-ls are torpiel they may be stimulated to action by a gentle laxative, or by an enema. If the secretion of urine is scanty and high colored, some diuretic infusion, as of mentha viridis, with small portions of SAveet spirits of nitre, may be given. DIPHTHERIA. Diphtheria was the first of these epidemics, making its appear- ance in some sectiems as early as 1855. From then, up to 1864, it prevailed in most parts of our country. It was thought by Ig4 DISEASES OF CHILDREN. many to be a iicav disease, though a reference to authorities will sIioav that several epidemics of the same have occurred before, and that it Avas well described, and received its name from French observers in the last century. Cause.—The cause of diphtheria is undoubtedly a specifie animal poison, though Iioav generated or propagated we are unable to tell. It prevails as an enelemic or epidemic disease, and is rarely if ever found in isolated cases. I have no doubt that it becomes contagious, like other similar diseases, Avhen it occurs in its most malignant form. There seems, sometimes, to be a very close relationship betAveen diphtheria and scarlatina, and cases have been recorded Avhere an eruption attended it. In this, as in some other diseases, the anomaly may have been a mistake in diagnosis, rather than a difference in the disease. Pathology.—I have not changed my opinion of the path- ology of diphtheria, first published in 1861, and upon Avhich the treatment of the majority of our physicians has been based. I 'quote it as then Avritten, desiring to keep it on record as being the first announcement of a doctrine that is now generally ad- mitted as correct. " I hold diphtheria to be a general as Avell as a local disease, as is proven by the languor, listlessness, torpor of the nervous system, and derangement of the excretory organs, which, as a general rule, precede all local disease; all being symptoms of perversion of the blood, and almost invariably indicating the establishment of febrile reaction. AVe also find the evidence of the perversion of the blood in the heavily coated tongue, which is always more or less discolored at the commencement of the disease, and ahvays in severe cases, exhibiting the brown- ish tinge, Avith more or less sordes upon the teeth as it pro- gresses ; in the diphtheritic deposit which is markedly different from the exudations from highly-vitalized blood ; in the secre- tion of urine in severe cases being abundant, in all cases dis- colored, frothy, more or less clouded Avith a peculiar, somewhat cadaverous odor—Avhat the ancients would have termed illy-con- cocted; in the evacuations from the boAvels, obtained by cathar- tics, Avnich are frequently large, dark, and almost invariably fetid ; and especially in the condition of the blood itself, Avhen the disease has attained its maximum, which is dark, is not changed diphtheria. 185 by expe)sure to air, forms a loose and easily broken-doAvn coa«u- lum, or does neit coagulate at all. " Post-mortem examination in t'nose cases that have run a reo-- ular course, /. e. that have not been terminated by an extension of the elisease to the larynx, sIioavs us the blood broken doAvn to a considerable extent, more or less discoloration of tissues from extravasation of the coloring matter, and softening of the tissues. These facts, it appears to me, prove conclusively the opinion given above." There are some cases in Avhich the disease seems almost wholly local, yet these are mild. Other cases will present the evidences of local disease first, and it Avill only be after some days that the serious character of the general lesion will be manifest. Symptoms.—As above named, the symptoms of the forming stage are similar to those of fevers and inflammations generally. For a day or two, sometimes for a Avcek, the patient is listless and languid, does not play with the usual zest, is fretful at times, does not sleep well, especially at night, drinks frequently, and has a variable appetite. FolloAving this is a slight chill, lasting one or two hours; not unfrequently it is so light that it is not noticed by the parents. Fedknving this, febrile reaction comes up sloAvly, and varies greatly in different cases. In some the fever is acute, and is a marked feature of the disease. In others the symptoms of fever are but slight—an accelerated anel se>ft pulse, arresteel secretion from the skin, kidneys, and bowels, and an increased temperature of the body, as marked by the thermometer, though it is not so perceptible to the hand. As the disease progresses the fever assumes an asthenic or typhoid character, and there is evidently a serious lesion of the blood. In a feAV cases the fever is high from the commencement, and continues to present sthenic symptoms during its entire progress. The patient complains or sIioavs signs of sore throat at the commencement of the elisease. There is difficulty and pain in deglutition, the child SAvalloAvs frequently to moisten the throat, and there maybe slight difficulty in breathing. On examination we find the mucous membrane of the fauces, tonsils and pharynx somewhat swollen, sometimes of a vivid red color, at others dusky or livid, and occasionally presenting a blanched appear- 186 DISEASES OF CHILDREN. ance. On some of these parts Ave will notice the characteristic exudation—spots of an ashen-gray or Avhite lymph upon the sur- face of the mucous membrane. They are usually small at first, not larger than a grain of wheat, or at farthest a three-cent piece. They are usually grouped together, two or three or more at a point, Avhich is more swollen or eliscolorcd than adjacent parts. There may be but one of these points of exudation, or several. As the disease progresses the swelling becomes more marked, and the points of exudation more numerous. The patches likewise increase in size, sometimes coalescing, so as to uniformly cover quite a large surface. For tAA'O or three days, in the majority of cases, the throat is dry, sometimes, indeed, during the entire progress of the disease. Then secretion is established from the mucous follicles, and some patches of exudation being removed, there is a free secretion from the denuded surface. The salivary glands also become more active, and the saliva is tenacious, thick, and ropy; and alto- gether the secretion is large, and requires frequent efforts at removal. Occasionally cases present themselves in which this seems to be the most unpleasant symptom. In the later stages of the disease, Ave may distinguish tAvo classes of cases. In the first the dryness continues, and the parts become stiff anel immobile, so that after a time deglutition be- comes almost impossible, and respiration is rendered very difficult and labored. Extending upward to the posterior nares and nasal cavities, these are closed bv the SAvelling ; and descending to the inferior portion of the pharynx and epiglottis, these and asso- ciated parts are swollen and rendered incapable of motion, and the chilel dies, partly from Avant of food and drink, and partly from imperfect aeration e)f the blood. In the second e-lass of cases, secretion commences about the second or the third day. By the fifth day it is quite free, some portions of the exudation are being detached, and the exposed surface secretes pus. In very severe cases this ulceration pro- gresses in every direction, but is mostly superficial. The tissues seem to have lost their vitality, and the muscles their power of contraction, and they hang feeble and pendulous and infiltrated Avith serum, Avhen the connective tissue is loose. Thus Ave have paralysis of the throat in the second as well as in the first case. This also extends upAvard to the nose, sometimes presenting the distinctive characteristics of diphtheria throughout. In some DIPHTHERIA. 187 of these the discharge will be profuse, in others it is retarded, becomes dried, and thoroughly closes up the passages. In other cases the disease extends downward and involves the pharynx. Here the child presents all the symptoms of croup— the whistling respiration, croupal cough, loss of voice, and gradu- ally increasing difficulty of breathing. The occurrence of the laryngeal complication is sudden, and it runs a rapid course. Thus, if not relieved by remedies, it will usually terminate fatally within forty-eight hours. Diagnosis.—Diphtheria is readily diagnosed by the specific character of the sore throat. AVhere there is the peculiar ashen exudation upon the free surface of the mucous membrane, there is a case of diphtheria, no matter what the other symptoms may be. AVlien there is no such exudation the disease is not diph- theria. I admit that in some exceptional cases the patches of exudation may be throAvn off very early, anel when the patient is first seen there Avill be simply an ulcerated sore throat, but in all there is the exudation*at some period. PnejuNexsis.—As is the case Avith all endemic and epidemic dis- eases, it prevails Avith elifferent degrees of severity in different places and at different times. Thus one physician may meet Avith it in a form so malignant and running its course so rapidly, that a majority of the cases Avill prove fatal. AVhile another will see it in a mild form, anel with but simple treatment a large ma- jority recover. Thus with some there has been a mortality of tAventy to fifty per cent., Avith others of not more than tAvo or three per cent., both pursuing the same treatment. Of course, in laryngeal complication the prognosis will be more doubtful. Treatment.—Diphtheria being a disease of the blood, the treatment will in all cases be general, with the addition eff local treatment in severe throat complications. Should nausea prevail, with heavily coated tongue, I Avould preface the treatment Avith the administration e)f a thorough emetic ; this Avill arouse the system and place the stomach in condition to receive other remeelies. In mv experience with this disease, in the greater number of cases taken from the commencement, I find Phytolacca te> be the most frequently indicated. It has a specific influence upon the blood, the glandular sy-tem, anth the throat. AVe may use it with the indicated sedative, or, as I prefer, in alternation with 188 diseases of children. Tinct. Aconite or Veratrum gtt. v. to x., Avater Siv.—Tinct. Phytolacca gtt. xx., water 5iv.; dose, a teaspoonful alternately every hour. If there is an excess of saliva, make a solution of potassa chlorate oss. to half a glass of Avater, and give the child a tea- spoonful four times daily. If there is fetor Avith ulceration, Thymol maybe given both internally and used with the spray. Py Thymol gr. viii., Glycerine, Avater, aa. §ii. M.; a teaspoonful once in three hours, and spray the throat three or four times a elay. With enlargement of the glands a local application of Phyto- lacca and glycerine Avill be excellent treatment. Tavo drachms of the first to an ounce of the last; saturate a flannel bandage and apply to the throat, reneAving tAvo or three times a day. Dusky color of face and mucous membranes, Avith typhoid symptoms, indicates Baptisia, Avhich may be given in the usual doses Avith Aconite. Children of scrofulous habits Avill improve nicely on Lachesis, and Lycopodium may be given Avhen there is a low grade of fever, Avith diminished secretion of urine. Cases may arise Avhere, in the latter stage of the disease, it Avill be necessary to use an emetic, but it Avill be in laryngeal compli- cations, and must be used Avith care. AVe may use the acetous emetic tincture in small doses, just sufficient to produce nausea and gradual emesis. Following the sedatives anel antiseptics must be the sustaining treatment. The temperature must be carefully noted at different periods during the day, and if it decreases, stimulants must be administered frequently, and in small quantities. Should high temperature prevail, Ave want to think of cooling remedies in addition to our sedatives. In malarial localities, Avith the system prepared for the antiperiodics, quinine should be given early in the disease. If there is no gastric irritation, but an alkaline condition, the better Avay will be to give the acidulated elixir. AVith an atonic condition, or congestion, I prefer the olive oil preparation Avith thorough friction. In the matter of local applications, there are two remedies that I prefer to all others : they are Phytolacca and compound Stillingia Liniment. As previously alluded to, the Phytolacca Avill be an essential part of treatment in all cases Avith enlarged glands, using it in combination with glycerine. The Stillingia liniment is a stimulant and an excellent counter-irritant, and may be used in both throat and lung complications. Satu- DIPHTHERIA. 189 rate a flannel cloth, and apply three times a day. It exerts a marked control over the croupal symptoms, when applied over the larynx. In mild cases Ave may use the hot vinegar pack. If there is stupor anel tendency to coma, or pain in the throat Avith difficulty in sAvalloAving, give Belladonna. Sepsis with deep redness of mucous membranes and slick tongue, Avants muriatic acid. If the tongue has a dirty coating, with pungent breath, and the excretions look as if fermented, the patient wants sul- phurous aciel. AVe may use the first as an acidulated drink, add- ing tAvo or three drops to half a glass of Avater, and let the child drink at pleasure. We get a much better action from the acid in this Avay than we should if syrup Avere added. Of the sulphu- rous acid, oss. to water 5iv., and given in teaspoonful doses every two hours, will give marked benefit. Occasionally Ave have a case calling for sulphite of soda. AVe recognize it by the pasty- white coat on the tongue, pallidity of mucous membranes, anel a general atonic condition of the Avhole system. The dose Avill be three grains every tAvo hours. Now come our cases of unusual severity : the patient is debil- itated, and the throat ulcerating Avith a sickening fetor. The disease has extended up into the nares, and the lips are parched, and may have soreles upon them. Treatment must be prompt anel decided, anel Ave turn with confidence to bichromate and permanganate of potash. The former Ave Avould use more par- ticularly in those cases of a croupy nature, accompanied by diffi- cult, Avheezy breathing, and great depression. From ten to fif- teen grains may be dissolved in half a glass of Avater, and given in teaspoonful doses every tAvo hours, alternating with Veratrum. Of the latter salt, we will add from five to ten grains to four ounces of water, and give a teaspoonful every tAvo hours. As adjuvants, I Avould recommend gargling, if the child is old enough, and spraying with the atomizer, or inhalations. AVater medicated Avith chlorate of potassium, salicylic or carbolic aciel, thymol, chloride of e-aleium, Avith muriated tincture of iron, and the vapor of hot vinegar, may be employed with success. Cloths must be kept at hand to absorb all discharges from the mouth, and burned immediately ; and the lips anel mouth sponged with a solution of thvmol or chlorate of potash. The little patient must be kept as quiet as possible, and the food will necessarily be of the most sustaining character, as beef essence, milk, and cus- tards of sea moss farina. 190 DISEASES OF CHILDREN. AVith this, as in other similar diseases, the general bath and the hot foot-bath are employed. In the majority eff cases a stim- ulant bath Avill be preferable, as of salt Avater with brisk friction, or the addition of capsicum or mustard to the Avater. The hot mustard foot-bath is a very valuable means, and may be used tAvo or three times daily, and for half an hour at a time. It is espe- cially important in severe cases, indeed in any case, that the ex- tremities be kept warm. I have often thought that in some it Avas just the difference between death and recovery. Let the feet and legs be cold for six hours, in a severe case, and the throat disease Avill have advanced beyond the reach of medicine. In the application of stimulants I prefer Capsicum, and the use of dry heat Avill be the best means. It is a very good plan to say to the nurse, " If complaint is made of any part, sponge it Avith hot water, and cover at once with hot dry flannel." Where the larynx becomes involved, anel the symptoms of croup developed, the treatment must be prompt and thorough, if we expect to save life. To give temporary relief, I direct the inhalation of vinegar and Avater sufficiently often to give ease, using at the same time hot fomentations assidulously applied to the throat. AVhen the case does not seem to be progressing rap- idly, I place the patient upon the use of Aconite and Phytolacca alone, using the Stillingia liniment as a local application over the larynx. If, hoAvever, it is progressing rapidly Ave may give the patient small doses of acetous tincture of Lobelia and San- guinaria, so as to keep up continuous slight nausea; and A\hen the patient is brought fully under the influence of the remedies, it is carried to free emesis. So far as my experience goes, how- ever, Ave haAre much better results if we folloAV the direct indica- tions, and give the small doses. ERUPTIA^E FEVERS. i The eruptive fevers are caused by a specific contagion gene- rateei during the progress of the disease, and propagated by con- tact, by inhaling the gaseous exhalations, or by the absorption of the poison from the clothing or the excretions. The poison is capable of being disseminated by the atmosphere to a limited extent in ordinary cases ; but when severe, and in numerous cases, it sometimes affects the atmosphere for considerable dis- ERUPTIVE FEVERS. 191 tances, especially in the direction of the prevailing Avinds; in these cases the disease assumes an epidemic character. In the most of these diseases the virus may be transmitted by inoculation. Indeed, in any Avay by Avhich it is brought in con- tact with the body, so that it may be absorbed into the blood, the disease may be disseminated. The causes of these diseases vary in intensity in different sea- sons, and in different localities, so that at one time they will be remarkably mild, anel at another time very severe, even malig- nant. It is pretty evident that the condition of the atmosphere, as regards heat and cold, moisture or dryness, and especially its electrical condition, has much to do with the intensity of these, as Avell as other diseases. It has been noticed that the eruptive fevers, as Avell as some other diseases, prevail in cycles, the periods being usually about seven years. This has been accounted for in the case of the class under consideration, by the fact that all the material for such disease is used up in its progress of tAvo or three years, and its reappearance depends upon the presence of a neAV population not protected from it. A peculiar feature of these diseases is, the immunity from them produced by one attack. It seems that in each of these cases, the cause of the elisease destroys all the material capable of being influenced, or all susceptibility to the influence in the first attack. As a general rule, the immunity from the influence of the cause a seconel time, is perfect after the first attack, and the person may be cxposeel without the least danger. There are some rare cases, hoAvever, in Avhich the person is not thus protected, and in which it may recur one or more times. These fevers differ from all others, therefore, that an attack protects the individual from ever having the disease again, even though being exposed to the same cause. They differ also in the specific character of the eruption, which is a part of the fever. Liebig thus accounts for the disease and its protective influ- ence : " AVhen a quantity, however small, of contagious matter, that is, of the exciting body, is introduced into the blood of a healthy individual, it Avill be again generated in the blood, just as yeast is generated from Avort. The condition of transforma- tion Avill be communicated to a-constituent of the blood ; and in consequence of the transformation suffered by this substance, a body identical Avith, or similar to the exciting or contagious 192 DISEASES OF CHILDREN. matter, Avill be produced by another constituent substane-c of the blood. The quantity of the exciting body neAvly-produccd must constantly augment, if its further transformation or decompeti- tion proceeds more sloAvly than that of the compound in the blood, the decomposition of which it effects. * * * In the abstract chemical sense, repre)ductie)n of a contagion depends upon the presence of two substances, one of Avhich becomes com- pletely decomposed, but communicates its own state of transfor- mation to the second. The second substance thus thrown into a state of decomposition is the neAvly formed contagion. * * When the constituent removed from the blood is a product of an unnatural manner of living, or Avhen its fe>rmatiem takes place only at a certain age, the susceptibility of contagion ceases em its disappearance. The effects of vaccine matter indicate that an accidental constitution o f the blood is destroyed by a peculiar process of decomposition, Avhich does not affect the other con- stituents of the circulating fluid." As in the case of sthenic fevers, the cause, in these diseases, seems to influence the blood almost in direct ratio to the func- tional disturbance. Thus, Avith an active fever, and arrested secre- tion, the poison seems te> be.generateel in increased quantity. In some cases the influence of the contagion does not cease with the formation of the specific virus, but originates a septic decomposition of the blood, giving rise to putro-adynamic symp- toms, which frequently result in death, sometimes e\Ten before the appearance of the characteristic eruption. VARIOLA-SMALL-POX. Small-pox, like other of the eruptive fevers, is caused by a specific contagion, generated during the progress of the disease in the human body. This contagious matter may be propagated by contact Avith the person or with articles of ch)thing, e>r indeed anything that has been in contact Avith him, and by inhaling an atmosphere impregnated Avith the poison. This atmospheric cause varies in different cases; in some extending but a short distance from the person, frequently confined to the room ; in other seasons extending considerable distances in the direction of the prevailing Avinds. The disease is, so far as AATe knoAV, ahvays produced by the one cause, the specific virus of small-pox, and is never generated VARIOLA. 193 anew or Avithout this. AVhile it is thus contagious, it also be- e-onu'.s endemic anel epidiemie by peculiar states of the atmosphere. It alse) prevails in cycles, as heretofore stated, some of these being milel, others severe. More commonly, perhaps, Ave have one or twe> years in each cycle, in Avhich the disease is severe, then others of a milder type. The virus of small-pox acts upon the blood, giving rise to such changes in this fluid as produce all the phenomena noticed, anel generating within it a virus similar to itself. Finally, this is throAvn upon the surface in the form of pustules, and the blood being freed from it convalescence ensues. AVe may, in this dis- ease, stiuly the pathology of all fevers, as this presents all the phenomena of a fever, with a cause tangible to our senses. AVe may trace the incubation of the virus in the body, as it gradually increases and influences all the functions of life. The gradually increasing prostration terminating in a chill ; the febrile reaction folloAving this, the eruption of the small-pox pustules, and finally the subsidence of the disease Avhen the virus is thus whclly removed. Symptoms —Small-pox is divided into tAvo classes, the discrete and confluent, though these are elifferences in its severity, ne>t in its character. In discrete small-pox the pustules are not so nu- merous but that they have room for full development upon the skin. In confluent small-pox the points of eruption are so numerous, that as they are developed into pustules they croAvd upon each other and run together, so that on large portions of the surface nothing is seen but the eruption, and, as it matures, the formation of a single crust. In the discrete form the premonitory symptoms are not severe. The child will be fretful, restless in its sleep, anel, if old enough, Avill complain of feeling tired. The chill is tolerably Avell marked, though not severe, and lasts from one to two hours. The febrile reaction comes up prettv actively, though it bears a closer resemblance to febricula than to the severer fewers. The eruption generally makes its appearance during the latter part of the second and during the third day, and at this time the fever has attained its highest point. By the fourth day the fever will have subsided, to a considerable extent, and from this to the tenth or tAvelfth day, is so slight as to give but little annoyance. At this time, Avhen maturation is complete, a secondary fever is developed, which, for a few hours, is pretty active. This passing 13 194 diseases of children. off, secretion is established, the appetite and digestion are restored, and the child convalesces rapidly. In the confluent form the premonitory symptoms are noticed earlier. The child appears depressed, its appetite is poe>r, it is restless and fretful during the day, and does not sleep soundly at night. As avc approach the period e>f chill these symptoms are more marked, and the child presents evident symptoms of suffer- ing. The chill, in this case, is usually Avell marked and pro- tracted, the temperature is really loAvered, the pulse increased in frequency, the skin contracted, presenting the cutis anserina, and in many cases there arc marked rigors. The febrile reaction comes up rapidly in most cases, and runs high. The surface is hot and dry, the pulse frequent, full and hard, the urine scanty, the boAvels constipated, the mouth dry, the tongue coateel Avith a Avhite fur, the face flushed, the eyes bright, Avith great restlessness and irritability. The child expresses evidences of suffering that can not be mistaken, and Ave suppose it has all the aches and pains that are pathognomonic of small- pox in the adult. The fever continues on Avithout abatement, rather increasing than othei-Avise, until the eruption makes its appearance. The symptoms of suffering pass aAvay after the first day, and there is usually not so much restlessness, though occasionally the irrita- tion of the nervous system continues to be a marked feature, and there may be convulsions and occasionally eATident delirium. About the time the eruption is making its appearance the throat seems to be stuffed up, and there is free secretion from it and the mouth. In some cases this becomes quite severe, the throat is SAVollen, and the secretion profuse and tenacious, Avhich render deglutition anel even respiration difficult. The eruption appears on the third day, at first on the face, then the trunk, and finally the extremities, usually not being fully out before the end of the fourth or the fifth day. In most cases there is a slight abatement of the fever after the eruption has made its appearance, presenting frequently a morning remission and evening exacerbation. It varies greatly in intensity in differ- ent eases. In some it is very active in all its symptoms, anel children are frequently delirious. In others it presents the usual symptoms of an infantile remittent. In the more malignant cases it is asthenic in character, and the symptoms are of a typhoid type. variola. 195 About the tAvelfth day from the chill, or ninth from the erup- tion, a secondary fever makes its appearance, and lasts from one to three days. Usually it is very active, and the child suffers more from the fever than at any time during the progress of the elisease. Maturation being complete, Avhen this fever declines, the secretions are re established, and the child sloAvly convalesces. Having described the general symptoms of the disease, we must iioav study the eruption. AVhen it first appears it simplv presents a small red spot, resembling somewhat a fleaor mosquito bite. These look as if slightly elevated, and Avhen Ave place a finger upon' one it feels hard, as if a small shot Ave re imbedded in the skin. On the second day the redness has increased in size, the elevation is more perceptible to the eye, and a minute point is seen in the center from which the future pustule is to be de- veloped. On the third day the red spot has increased in size still more, and in its center is seen a small vesicle, distinctly rounded in form, and filled Avith a clear, limpid serum. On the fourth day this has increased in size, is flattened, seems to be tied down in its center—umbilicated—and the lymph is becoming yellowish and opaque. On the fifth day it has attained about one-half its size, is yellowish and opaque, distinctly umbilicated, and stands on a SAvollen base, and presents a red areola. Continuing to increase in size it attains its maturity by the ninth day, Avhen it is three-eighths to one-half inch in diameter, the red areola being about as much larger; it is yelloAvish and opaque, and distinctly umbilicated. The tumefaction of the base, Avhen the points of eruption are numerous, is such as te> give a uniform SAvelling of the surface. Thus, in the severer cases, the eyes are closed, and the features so effaced that the person coulel not be recognized. AVhen maturation is thus completed, some of the pustules burst anel discharge a portion of their contents. In all it desic- cates, and forms a crust or scab, which is retained in contact with the skin by the epithelial investment of the pustule. In from three to nine days this gives Avay and the scabs are throAvn off. The parts, where they are developed, present a bluish or livid appearance, Avhich sloAvly passes away in some five or six weeks, though it can be noticed for as many months Avhen the person is exposed to the cold. In some cases a process of ulceration is set up at the base of the pustule, and the true skin is destroyed, to a greater or less 196 DISEASES OF CHILDREN. extent. This causes those depressions that Ave call pitting, and Avhich are never effaced. Small-pox may be complicated Avith inflammation of anv oroan or part. These are not very common, ami are usually recexniized with ease. There are some irregularities in its progress, however that should be studied with care. In one, the disease having progressed to the fourth day, Ave finel the skin swollen, and as- suming a dusky appearance; yet the eruption does not come out, or appears sparsely. At the same time we finel the child becom- ing comatose, and also that this is influencing every function of life, until finally death results. In a seconei, the eruption having made its appearance, recedes; the skin is SAA'ollen and dusky, and coma comes on, as in the preceding case. In malignant small-pox—that in olden times received the name of black small-pox—the skin seems swollen and dusky from the commencement. AVhen the eruption makes its appearance it also is discolored, and the pustules, instead of being yellowish, have a shade of broAvn or black, or in some cases are black. This is associated Avith the brown tongue, sordes on the teeth, frequent small pulse, and other typhoid-symptoms. Diagnosis.—The diagnosis of small-pox is not difficult. The symptoms preceding the chill for some tAvo or three days,—this being marked, and followed by high febrile reaction, in which the child evidently suffers much pain,—are sufficient to arouse our suspicions. The eruption of red points, hard under the finger, is the diagnostic evidence at this time. Afterward the umbilicated pustule and its regular and sIoav development, distinguish this from all other eruptions. Prognosis.—I regard the prognosis of small-pox as favorable, except in those exceptional cases last described. Of course, some children will succumb to even its milder form, because they have not vitality to liA'e through any disease. The mortality attend- ing small-pox seems to have lessened in the ratio that the people are protected by vaccination, thus proving that the virus gains intensity as developed from a large number of persons at the same time. Treatment.—It is contended by the majority of writers that small-pox is a self-determined disease, and has a regular course to run, and that this can not be modified or shortened. In this VARIOLA. 197 respect it is said to resemble typhoid and other continued fevers. I admit the resemblance, and contend that its course can be both modified and shortened, as Ave have proven to be the case with continued fever. We have the evidence of this in the history of inoculation. Here the small-pox virus was introduced into a system not pro- tected, but by a system of diet and means to promote the secre- tions, it Avas caused to run a very mild and also a short career. If the small-pox virus is generated within the blooel, and this is the cause of the disturbance Ave Avitness, that disturbance will be less, just in proportion as this is developed slowly and re- moved by the excretory organs. There is no doubt but that the virus of small-pox may be removed by the excretory organs in very considerable quantity. AVe have already seen that the development or activity of such blood poison Avas in the ratio of the frequency of the circulation and other functional derange- ment. If, therefore, Ave control the circulation, and establish function, Ave will lessen the rapidity with Avhich the virus is generated, and arrest the septic decomposition that accompanies it; and if, at the same time, Ave stimulate excretion by the skin, kidneys, and bowels, we Avill remove considerable portions of it, and thus lessen the eruption upon the skin. It will be observed that the theory is good, and is based upon facts constantly Avitnessed in other eliseases. Experience, also, which is the test for every neAV doctrine, confirms these views. The treatment, then, will be the same as for any other femn of fever. AVe put the patient upon the use of Aconite or Veratrum. in the usual doses, aieling their action by the general sponge-bath and the use of the hot foot-bath. If there is much irritation of the nervous centers, Avith determination of blood, avc adel Gelse- minum ; but if the patient is dull and torpid, and inclined to coma, Belladonna is used instead. The most pronounced symptom in the first stage of small-pox is the severe pain, and this suggests remedies that relieve pain. Macrotys has been employed for a half century in these cases, and so marked is its action that many have called it a specific in small-pox. Bryonia will be found an excellent remedy Avhen the patient complains of pains in the chest, with severe cough, or uneasiness in the boAvels with tenderness, or pain in the articu- lations. Rhus is an admirable remedy in some cases, and will be indicated by burning pain, by pain in the forehead, and also 198 diseases of children. by pain in the neck and occiput, the tissues being very sore and painful Avhen pressed. Among the remedies to bring thcerup- tion to the surface, when it is tardy, there are none better than Belladonna when the patient is dull anel inclined to sleep, and Rhus Avhere it is restless, uneasy anel Avakeful. By the second or third day of the treatment Ave may adel a portion of the tincture of Asclepias to the sedative mixture, anel commence the administration of a solution of Acetate of Potash 5ss., to Avater 5iv.; a teaspoonful every three hours. This is used Avhen the fever is active and the disease sthenic in character. The boAvels are kept in a soluble condition by the use of laxa- tives, but cathartic medicines of an irritant character are very objectionable. Citrate or carbonate of magnesia, manna, phos- phate of soda, or castor oil, may be used, or in place of them Ave may depend upon enemata. In some cases Ave find the tongue broad and much furred, the breath bad, anel the stomach in such condition that it can neither digest food nor receive remedies kindly. Generally this may be regarded as an unfavorable commencement of small-pox, and demands prompt treatment. AVhen marked, I would strongly advise the use e>f an emetic, so given as to obtain a thorough action, then continuing the treatment as above named. AVhere this condition is not so marked, the sulphite of soela may be employed, in doses of five grains every tAvo hours until removed. Even when an emetic has been used, it Avill be well, in some cases, to fdlow it with the sulphites. In the case named, Avhere the eruption is tardy in its appear- ance, Ave may use the hot-pack or the emetic, or both. In giving a hot-pack, in this case, I have an ounce of mustard added to a couple of gallons of water, and Avhen hot Avring a blanket out of it quickly and envelop the chilel, covering Avarmly Avith dry blankets or comforts. In the majority of cases it Avill be more convenient to use the stimulant vapor by means of hot bricks, as heretofore named. The emetic of Lobelia is the most poAverful means Ave have, if properly used. It is given so as to produce its general influence, anel then carried to thorough emesis, as Avas named in congestive anel spotted fever. So also in those cases in which there is a retrocession of the eruption. The emetic arouses the nervous system, throws off the cause, and re-establishes a free and equal circulation of blood. It may be used alone, or associated with the hot stimulant bath. VARIOLA. 199 If the disease sIioavs evidence of a septic condition of the blood, no class of remedies will give better results than the sulphites. The sulphite of soda is probably the best, and may be used freely, the indication being a broad pallid tongue, coated Avith a dirty white fur. If the tongue is red, moist, and covered with a glu- tinous mistiness like fecal matter, sulphurous acid will be the remedy, giving it in teaspoonful doses every three hours. Sul- phur may also be burned in the room to purify the air, and the bed utensils may be disinfected in the same Avay, or by the use of chlorinated soda. In some cases, and these very severe ones, Baptisia will be indicated from the commencement. The full leaden or purplish face, like one Avho has been exposed to severe cold, is the best indication for the remedy. Sometimes the patient shows this fullness anel unpleasant color over the-entire surface, anel even the mucous membranes Avill bear the tint. Baptisia is added te» the sedative mixture in the proportion of gtt. x. to gtt. xv. to water 5iv. It is an admirable remedy, and I should hardly knoAV Iioav to treat these unpleasant cases without it. Occasionally muriatic acid, or a good sharp eider, or Avhey, will serve a good purpose; the last making a very good diet drink in these cases. Chlorate of potash will sometimes be indicated in small-pox, but in this, as in other cases, Ave follow our nose—the bad odor being the indication. Te> relieve the unpleasant condition of the throat during the first days of the eruption, Ave order a gargle of sulphite of senla, chlorate of potash, or Baptisia, when the child is old enough to use remedies in (his Avay. AVith younger c lildren these remedies may be used with a spray apparatus, or by inhaling the vapor from them when heated. Usually, when no apparatus is at hand for using inhalations, Ave will find the vapor of vinegar and water to ansAver a good purpose. To prevent pitting I depend wholly upon cleanliness, keeping the room darkened to obviate the irritant action of light. Using olycerine soap, I have the exposed parts Avashed Avith a soft sponge several times a day, so as to keep them clean and soft. Occasionally a soft and thin cloth, Avet with equal parts of glyce- rine and Avater, may be used when parts sIioav considerable irri- tation. "With quite a large experience in the treatment e»f the disease the results of this method have been very satisfactory. 200 DISEASES of children. The sedatives are continued during the Avhole progress of the disease, so as to control febrile reaction ; anel generally Avhere the treatment as given is pursued, there will be but slight secon- dary fever. AVhen this comes up, however, it is controlled by increasing the frequency of the dose. Throughout the progress of the disease, Avhich is exhausting in its character, especial pains should be taken to prevent irri- tation of the digestive organs, anel to support the strength by appropriate food. AVhen the child is nursing the mother's milk is sufficient, and is the best fooel. At a more advanced ao-c, boiled milk, slightly salted, taken hot, Avill be more kindly re- ceived and better digested than most other food. In some cases it will be necessary to support the strength of the patient by the use of the bitter tonics and iron. Quinine with Hydrastine, in doses of one-half grain, is generally our best prescription. This may be aided by the muriated tincture of iron Avith glycerine, as heretofore named. AVhen the mucous membranes present a dark-red or dusky appearance, the dilute muriatic acid Avill ansAver the best purpose. VARIOLOID. Varioloid is small-pox modified by the vaccine disease. In some persons the coAV-pox is but partially protective, or it may be wholly protective at first, but as time passes, the susceptibility to the virus of small-pox is gradually reproduced. Upon Lie- big's theory, the material in the blood, upon which the small-pox poison acts, is reproduced in smaller quantity. Varioloid is small-pox in every sense. It is produced by the specific contagion of small-pox, and in turn it generates a virus which Avill give rise to the fully developed disease in a person not protected by vaccination. It differs only in that the symp- toms are milder, and it runs a shorter course. The symptoms are usually those of the discrete form of small-pox. The febrile action subsides Avith the appearance of the eruption, or in the severer cases is remittent in character, and not severe. The pe- riod of maturation is generally but seven days, and the secondary fever is short and mild. The desiccation and removal of the crusts or scabs is also rapid, so that by the tAvelfth to the fif- teenth day the surface is pretty Avell freed from. them. variola vaccina. 201 It is not necessary to give the treatment of varioloid, as it Avould be but a repetition of that just given under the head of small-pox. VARIOLA VACCINA—COAV-POX. Prior to the year 1721, no prophylaxis against small-pox was known in Europe, if Ave except the practice of buying the small- pox that prevaile.-d at a very early period be>th in Wales and Scotland, and Avhich, in fact, Avas inoculation. The practice of inoculation, according to the statements of the Jesuits, Avas em- ployeel imineinorially in China, and by the simplest method, that of passing a needle chargeel with the virus through the skin Avhen it was pinched up by the finger. The practice e>f inoculation was introduced into England in 1721, by Lady Alary Memtague, who had Avitnessed its success in Turkey, and had a son successfully inoculated. The practice met Avith much opposition, as all innovations upon established cus- toms anel prejudices do, and it was not until about the year 1750, that it received the cordial support of the medical profession. At first a stimulant and heating treatment Avas pursued, as Avas the case in small-pox, anel the mortality Avas considerable. After- ward a " refrigerant and reducing" plan Avas adopted, Avhich Avas attended Avith much success, anel from this time the practice came to be regarded Avith favor. The vaccine disease or coAV-pox, as a prophylactic against small-pox, Avas discovered about the year 1775, by Dr. Jenner, though he did not publish it until 1798. He noticed, while first studying medicine, that in the dairy districts of Gloucestershire, there Avas a current opinion that persons avIio had been affected Avith a peculiar eruption knoAvn as coav-pox, Avere protected against the contagion of small-pox, and might go among it and nurse persons affected with it, with perfect immunity. His mind was strongly impressed with these facts, anel he commenced their investigation. It Avas not until 1796, however, that he became sufficiently convinced to attempt the pmpagation of the disease by inoculation, or as Ave sav, by vaccination. His first case Avas entirely successful, the elisease was transmitteel, the pustules formed as elescribeel, and two months afterwards, upon being inoculated with small-pox virus, it was found not to have the slightest influence. 202 DISEASES OF CHILDREN. Dr. Good, in his stiuly of medicine, writing about the year 1822, gives the following account of the discovery, which, as a matter of historical interest, I quote: " The disease attracted attention in the county of Dorset, about fe>rty or fifty years since, as a pustular eruption derived from infection chiefly, showing itself on the hands of milkers who had milked cows similarly disordered. It had been found to secure persons from the small- pox ; and so extensive Avas the general opinion upon this subject even at the time before us, that an iimeulutor, who attempted to convey the small-pox to one Avho had been previously infected with the cow-pox, Avas treated Avith ridicule. A formal trial Avas made, hoAvever, and it Avas found that no small-pox ensued. About the same time, a farmer of sagacity, of the name of Nash, duly attending to these facts, had the courage to attempt artifi- cial inoculation on himself; anel the attempt is said to haA*e suc- ceeded completely. Similar facts and numerous examples of them Avere accordingly communicated to Sir George Baker, who, having engaged not long before in a most benevolent, though highly troublesome controversy respecting the cause of the en- demical colic of Devonshire, was unwilling, notAvithstanding his triumph, to tread again the thorny paths of provincial etiology. Gloucestershire, however, another dairy county, had Avitnessed the same disease with similar consequences; and the same opinion generally prevailing in distant districts of both counties, afforded proof that the power thus ascribed to coAV-pox Avas not wholly visionary. " Dr. Jenner, then resident at Berkley, in Gloucestershire, pursued this hint Avith great judgment and unabated ardor. He AAras at first foiled by not distinguishing betAveen the genuine coAV-pox and an ineffective modification of it, or a spurious dis- ease of nearly similar appearance, to which the same animal is subject, but which is no preservative against the small-pox ; and found another difficulty in determining the period of time Avithin Avhich the vaccine virus maintains its prophylactic poAver. Hav- ing at length made himself master of the distinctive characters of the genuine ATesicle, he ventured to publish the discovery in 1798, and to recommend inoculation with the virus of vaccinia as a substitute for variola." The discovery Avas not received by acclamation, and its discov- erer hailed as a benefactor of his race, as manv persons Avould imagine ; but, on the contrary, it Avas met by ridicule and denun- VACCINATION. 203 ciation, and Dr. Jenner lost business and property, and narroAvly escaped personal injury several times at the hands of a mob. The me.lical profession was as slow to admit the truth of the discovery, and as fast to cast obloquy on the discoverer, as the people; and it was many years before the doctrine and the man were admitted to be orthodox. The disease of the coav is of rather rare occurrence, even in England, and hardly ever manifests itself except when cattle are gathered together in herds. AVe have no authentic account of it ever having prevailed out of England, and feel sure that it has not occurred in this country. The supposition that it is small- pox modified by passing through the cow is an error reproduced every feAV years, generally to make a sale for vaccine virus from some particular person. Dr. Jenner thought that he had traced the cause of the disease of the coav to the grease of horses. In regard to this Dr. Good remarks: "It Avas fortunate for Dr. Jenner, and the triumph of his discovery, that a minuter attention to the subject gave sufficient proof that there Avas no foundation for this opinion ; and that Avhatever be the prophylatic power of the matter of the disease called grease, this disease is by no means the origin of the natural cow-pox, and has no connection with it." Vaccination.—Vaccination is not so easy an operation as thought by the majority of physicians. True, it is very simple, and there should be no reason for Avant of success, when good virus is used ; yet an extended acquaintance Avith physicians of all schools, proves that from its imperfect e>r careless perform- ance, it fails fully one-half the time. The cause's of failure are tAVO-fold. In one case the skin is not so abraded as to bring the virus in contact with the true skin, Avhere it may be absorbed. In the other the punctures are so deep as to cause a free flow e>f blooel, anel the virus is Avashed away. A vcrv simple and good method is, exposing the arm at the insertion of the deltoid, make the skin tense Avith one hand, anel holding the lancet in the other at an acute angle with the arm, make many slight punctures over a part as large as a three cent piece, elevating the epidermis without much bleeding. Now take the virus, se)ftened to the consistence of'cream, and spread e)n the punctures, either letting it dry by exposure to the air, orcov- erino- it with adhesive plaster, before the sleeve is drawn doAvn. 204 DISEASES OF CHILDREN. AVhen there is a failure with the lancet used in this Avay, try the Chinese method. Charge a fine needle with the virus, raise a portion of the skin between the thumb anel finger anel pass the needle through. An instrument has been devised for this pur- pose, Avhich answers well, being speedy, certain, and not painful. It consists of a small cupped stylet, throAvn by a spring; the virus being placed in the cup, anel the spring drawn back, it is discharged into the skin Avith a single stroke. Formation of the Vaccine Vesicle.—As a general rule, the punc- ture disappears the second day, but about the fourth or fifth day, a minute inflamed spot is seen. This gradually increases in size, and is swollen and hardened, and forms the base of the vesicle, Avhich is seen first about the sixth day. At first it is spherical and filled with a transparent limpid fluid, but as it increases in size it becomes flattened, and Avhen it attains maturity the center is loAver than the circumference. It requires twelve or fifteen days from vaccination for the full development of the vesicle, which iioav presents the folloAving appearance : It is regular in its outline, being usually o\~oid, though sometimes circular in form. The vesicle is uniform in its elevation, usually about one-eighth of an inch, is flattened, or even depressed at the center, and has a peculiar pearly-gray color. It stands upon an indurated and inflamed base, Avhich forms a red areola of from half an inch to an inch outside of the vesicle. About the tAvelfth day of the vesicle desiccation commences, and in four or five days is complete, though the scale or scab is not loosened for some time. The scar left by vaccination is peculiar, yet is simulated by spurious vaccination. It remains Avhite, the skin seeming to be deprived of its rete mucosum or colored layer, is depressed, the outlines being clean cut and well defined, and presents many little pits or depressions into the true skin. Generally there is slight febrile reaction about the eighth day, when the vesicle has attained its maturity. Occasionally there is a marked chill, nausea and vomiting, and for a few hours the chilel is quite sick. Sometimes the irritation of the arm extenels to the axillary glands, anel these become enlarged and painfeil, anel in some exceptional cases they have been knenvn to suppurate. Spurious Vaccination.—Any deviation from the course above described may be designated as spurious, and will not prove pro- VARIOLA VACCINIA. 205 tective. Ilcgular in form, uniform and.even border, flattened and of equal elevation, slight depression in the center, pjearly-gray in color, uniform period of development about nine days, gradual and even desiccation, and slow detachment of the crust. This is the vae-cine eruption, anel is so distinctive that I think it need not be mistaken. Spurious vaccine matter is produced in several Avays. It may be from decomposition e>f the A'accine lymph, by keeping, especi- ally Avhen moistened, and carried in the pocket, Avhere the tem- perature Avill be high. I Avas acquainted with an example of this kinel, in Avhich a suppurative disease in some half dozen children Avas produced by such lymph. The most common cause, as I belieA7c, is the use of seconel crusts from the vaccine vesicle. In many cases the vesicle haying fully developed, the lymph commences to desiccate, but before completion the par- tial ly-formed scab is rubbed e>ff or is removed by some accident. But another one shortly forms, principally from pus secreted as the result of the irritation. Of course, if this should be used for vaccination avc Avoulel introduce pus instead of vaccine lymph. If the general health Avas deteriorated in such person, and the blooel Avas bad, anel they Avere suffering from any cachectic dis- ease, the results of such A'accinatiem might be very unpleasant. Fe>r in some of these cases the pus possesses a peculiar septic property, that will cause extensive ulceration. I am satisfied that this Avas the case in the spurious A'accinatiem (from the army) that Avas pre>pagateel through many sections of our country, and Avas regarded by some as syphilitic. In every case that I couhl trace, the soldiers vaccinated had been in the hospital, with health broken doAvn by the fatigues, privations, anel sometimes dissipations of the army. Even when the vaccination was good anel protective, Avhich was not often the case, a suppurative in- flammation folloAved at the site of the vaccine vesicle, and the scabs formed contained pus from bael blood. I had a very marked example of such spurious vaccination, in mv oavh practice. A daughter of mine, in perfect health, was visiting her grandmother, and a case of small-pox having oc- curred in the village, pee>ple became excited, anel almost the entire population was vaccinated. A young lady employed in the house, having a very perfect vaccine vesicle, the child was vaccinated with lvmph from her arm, and it also took well, and developed regularly, and was as perfect as Avas possible. But, a 206 DISEASES OF CHILDREN. couple of days before coming home, while playing with other children, she struck her arm, and the partly-formed scab Avas detached. But a new one forming, it looked Avell Avhen I ex- amined it, and as there could be no doubt of the health of both the parties, I concluded that I Avould use it in my practice in place of others. The winter course of lectures had just com- menced, and, as usual, I vaccinated a majority of the students, using this virus. It did not produce the characteristic vaccine disease in a single instance, but quite a number hael very sore arms. Four Avere so severely affected as to be confined to their rooms, and in one the local ulceration and infiltration e)f tissue Avas such that I feared the gentleman would lose his arm, if not his life; but, having a good constitution, he recovered. This unpleasant experience has caused me to be ATery careful in the use of vaccine, and, under no circumstances, will I em- ploy a second scab, Avhether the first has been detached naturally or by some injury. Can Syphilis be Transmitted by Vaccination f—I ansAver this question in the negative, to this extent—that the use of vaccine lymph Avill never convey the disease. To make the answer pkiner, Avhere the vaccine disease runs its regular course, and the vesicle formed presents all the characteristics of that de- scribed, the lymph from this is like pure gold, and is not influ- enced by any constitutional peculiarity or any disease of the patient. But if it varies from this standard, is irregular in feirm and elevation, and yellenvish or pus-like in color, then disease may be transmitted, for it is not vaccine, but something else Or, if running the normal course of the vaccine disease, there is after- ward irritation and ulceration, pus being formed, this may be in such quantity in the scab, especially at its base, as to be a cause of disease. Or if the first scab is dctacheei by injury, the second one, being formed principally of pus, the use of this for vacci- nation may transmit disease from one to another. Feir many years the medical Avorld, following the lead of Ricord, denied that secondary lesions Avere transmissible. Hence, syphilis could not be transmitted as above, unless there Avas a primary source at the part of vaccination, Avhich could only occur by careless handling of a person having the primary dis- ease upon the genitals. But it is iioav conclusively proven, and even Ricord admits, that certain secondary lesions may be trans- RUBEOLA. 207 mitted by inoculation, and among these are pustular eruptions. Thus Ave have an additional reason for care that the lymph Ave use is the normal and regular product of good vaccination. This Ave can ahvays determine, while it would not be possible fe)r us to learn or discover constitutional taints upon the part of many patients. That our population is being slowly and insidiously infected Avith syphilis, through vaccination, as some Avould have us be- lieve, has no foundation in fact. On the contrary, the spread of the disease depends upon the licentiousness of the people, especi- ally the young men of the country, and the Avant of laAVS regulat- ing houses of prostitution. Preservation of Vaccine Lymph.—Vaccine lymph undergoes spontaneous decomposition, or at least loses its specific properties in a period varying from two to eight weeks. Hence extra pre- cautions are required to preserve it from season to season. It is most convenient to vaccinate from the crust or scab, and this is most commonly used. For a short time it may be kept between tAvo pieces of Avax, or inclosed in this manner, additional security may be given by an envelope of tin-foil. But Avhen Ave Avish to keep it through the summer, Ave envelop the scab in tin-foil, pressing it down tightly, so as to render it Avater-proof, and drop it into a bottle of glycerine. I do not know how long it might be presented in this Avay, but I have kept it in an active condi- tion for a year. RUBEOLA-MEASLES. Measles is a disease of childhood, though it may occur at any age, and becomes more dangerous as the person is advanced in years. Like the other erupuVe fevers it is caused by a specific contagion developed during the progress of the disease, anel may be propagated in the same Avay, by contact or by breathing an atmosphere impregnated with the poison. Like the others, it alse> prevails in cycles of from five to seven years. In some sea- sons and localities it Avill appear in a very mild form, while in others it will be more or less malignant. Symptoms.—From seven to fourteen days after exposure, the disease is ushered in with a chill, sometimes slight, at others amounting to a rigor. Occasionally for a day or tAvo before this the child manifests catarrhal symptoms, has a slight cough, and 208 DISEASES OF CHILDREN. may complain of pain in the head and back. Following the chill, febrile reaction comes up, but varies greatly in different cases. In some it is quite active, with a flusheel hot skin, freepient, full hard pulse, and considerable irritability of the nervous system. In all cases the catarrhal symptoms are so prominent anel constant, as to be regarded as almost pathognomonic. About the time of the chill, the chilel seems to have taken a severe cold, sneezes frequently, stuffing up e>f the nose, Avith increased secre- tion and discharge, redness and Avateriug of the eyes, increaseel sensibility to light, hoarseness, and a troublesome dry bronchial cough. The febrile reaction is usually remittent, anel continuing to increase gradually to the secemd, third, or fourth day, then de- clines after the eruption has fully made its appearance. The eruption comes out first on the face, neck and breast, then on the balance of the trunk, and finally upon the extremites. The single point of eruption is much the color of a musquito bite, ovoid or irregular in form, especially irregular in its border, and the color is gradually shaded off to the color of the skin. The points of eruption generally coalesce, so as to present larger patches or blotches. In \'ery severe cases, the Avhole surface will be thus covered so as to present but little of sound skin. The eruption is slightly elevated, and rough when the finger is passed over it, and pressure momentarily removes the color. It requires from twenty four to seventy-t.AVO hours for the full appearance of the eruption. It retains about the same degree of redness for one or tAvo days, and then sloAvly declines, so that about the sixth to the ninth day from the chill, it has passed away. During the one, two or three days in which the eruption is coming upon the surface, the fever is higher than before, anel sometimes the little patient is quite sick, even in the ordinary form of the disease. Then it declines, sometimes slowlv, re- appearing at times until the efflorese:ence has entirely passed away; at others, the little patient will be free from it in the course of a day. AVith the appearance of the eruption the bronchial irritation and cough are markedly increased in some cases, and become very troublesome. There is also more or less difficulty of breath- ing, which sometimes depends upon determination to, or conges- tion of the bronchial tubes, and at others upon similar lesions of the parenchyma of the lungs. The part affected, and also RUBEOLA. 209 the character of the lesion, may be determined by physical examination. Malignant Rubeola.—As named above, measles prevail Avith varying degrees of severity, from the very mild to the most malignant. AVe will also find that all the cases of a season re- semble one another—when the disease is mild, all cases are mild—when it is severe, all cases are severe. Of the cause of this malignancy Ave know but little, further than that the conta- gious virus once attaining malignancy, propagates itself in the same Avay. In one class of cases the eruption is tardy in its appearance; the fever running a pretty active course, with considerable bronchial disturbance, the third, fourth, fifth, or sixth day passes Avithout its full appearance. The surface seems slightly swollen anel flusheel, anel in some places the eruption is seen indistinct as if struggling to make its appearance. In the children of my oavh family, the eruption made its appearance, respectively, in five, eight, anel thirteen days from the chill. Necessarily, in such cases the bloenl must become impaired by the long retention of the rubeeilous poisem, and the symptoms presented will be more or less of a typhoid character. In another class of cases, the symptoms of malignancy are manifested early in the disease. The pulse is smaller anel faster, the skin flushed, but dry and husky, and the tongue covered with a dirty fur with a tinge of brown. The nervous system suffers especially in these cases. In some there is great excitement fe>r the first day or tAvo, even delirium, or occasionally convulsions, afterwards coma. But in the majority of cases dullness and hebetuele are marked symptoms, the child dozes Avith its ewes partly open, anel early coma comes em anel gradually increases until the child can not be aroused from it. In all of these severe cases the eruption is more or less dusky, anel Ave may judge A'ery closely of the severity of the disease by this. It Avill also b^ a guide in the treatment, Means that brighten the color of the eruption are beneficial, but if the duskiness increases, Ave may be satisfied that our treatment is productive of no benefit, Retrocession.—There may be a retrocession of the eruption of meash's, at any time after it has appeared. In the milder form of the disease, this increases the fever and the bronchial 14 210 DISEASES OF CHILDREN. irritation, and though unpleasant is not dangerous. But in other cases Ave will find the nervous system suffering severely from the retrocession, and if it continues the blood also becomes impaired. In these cases dullness, stupor, and coma follow one another rapidly; the skin is dusky, the temperature increased, and the tongue soon becomes bi'OAvn, and sordes appear upon the teeth. These symptoms are of a grave character, and unless prompt means are employed to bring the eruption again upon the sur- face, it may terminate fatally in a short time. The Sequelae of Measles.—An irritation of the bronchial tubes and larynx, Avith a harassing cough, is very frequently left from measles. In some cases this seems to be the result of cold taken during the progress of the disease, or more frequently, shortly after the child has commenced getting about. The cough is very harassing, causes restlessness and broken sleep, affects the appetite and digestion, and indeed, all of the vital functions. Continuing, the bronchial irritation produces structural change, and after a time develops true phthisis. A less common sequel of measles, is a subacute inflammation of the conjunctiva, principally confined to the lids, and finally terminating in granular lids, or ophthalmia tarsi. In some other cases, otorrhoea results, and proves very stub- born. Deafness, partial or total, may also be produced by measles. The partial deafness is usually OAving to disease of the Eustachian tubes, though it is sometimes of the middle ear. Diagnosis.—The marked catarrhal symptoms is the principal diagnostic feature in the early stage of this disease, as the severe pain is in small-pox, and the sore throat in scarlet fever. AVe distinguish the eruption by its irregular form, coalescing in blotches, not presenting the hardness of small-pox, or the vivid redness of scarlet fever. Prognosis.—The prognosis in measles is favorable; even in the malignant cases, if properly treated, there should be but a small mortality. It is true that in some epidemics in large cities, the disease is very severe and typhoid in its character, yet I think that the great mortality attending it is to be attributed to the medication as much as to the disease. RUBEOLA. 211 Treatment.—The treatment of measles is usually very simple. Bathe the patient's feet fe>r half an hour in hot Avater, and give internally an infusion of tAvo parts of Asclepias and one of Lobelia herb. It need not be given to produce nausea, though to the extent of slight nausea it favors the appearance of the eruption. After the eruption has made its appearance I fre- quently continue the same remedy in small doses, to relieve the bronchial irritation and check the cough. In place of this Ave may put the patient upon the use of Vera- trum or Aconite, in small doses, Avith gtt. x. to gtt. xx. of Lobelia to water o'iv., using the general sponge-bath at first, and the hot foot-bath to favor their action. This is not associated Avith Avarm teas anel stimulants as so commonly used, but on the contrary the patient is kept quiet in bed, not too Avarmly covered, and is alloAved cool drinks. If the cough is very troublesome, Ave may give an infusion of dried red clover, or from the pocket case, Tinct. Drosera gtt. x. to gtt. xx., water 5iv., a teaspoonful every three hours. If there is anything specific in medicine it Avill be found in the use of Drosera in the cough of measles anel in Avhooping cough. In some cases Ave find the patient very restless, starting in sleep, with shrill cry, and Ave fear convulsions. The pulse is small and sharp, ami the skin dry, contracted and burning. The remedy here Avill be Rhus, and its action is very prompt and kindly. Gelseminum, Bryonia, Apis, Phytolacca, Eupatorium, and other remedies, Avill finel a place in the treatment of this dis- ease, being guided by the special indications as heretofore giAren. AVhen bronchial irritation is great, or passed into the state of inflammation, we will find the use of an inhalation of the vapor of Avater, either alone, or medicated with Lobelia, or Avith some of the narcotics, will answer a better purpose than the usual inter- nal remedies. A mush poultice applied to the chest in older children, and continued until the irritation is relieved, answers a good purpose. But Avith young children I prefer a cloth spread with lard, and sprinkled with the emetic poAvder of the Dispensatory. Much care is required after the disease has subsided in order to confirm convalescence. The clothing should be warm, and the child not permitted to expose itself to draughts of air. If this is attended to and the secretions kept free, there is no more danger from measles than from any other disease. 212 DISEASES OF CHILDREN. In malignant rubeola avc Avill have te> give the case cle>ser atten- tiem. The first evidence of the character of the disease in young children will be manifested in the stupor anel tendency to coma. This Avill be met by the use e>f Belladonna with Aconite, in the de>ses heretofore named. Theuigh the case seems grave te> trust to such small eloses, yet a considerable experience has given me great confidence in Belladonna as a specific against congestion, especially of the nervous system. AVith this I put the patient upon the use of the anti-zymotics, to antagonize the septic condition of the blood; either of these remedies may be indicated. Sulphite of soda, if the tongue is broad, pallid and dirty ; sulphurous aciel, if it is deep-red anel moist, and covered with a glutinous nastiness; muriatic acid, if it is deep-red, contracted, dry and covered with a broAvn coat; Baptisia, if the patient sIioavs that full livid face as of one ex- posed to severe cold; and chlorate of potash, if Ave have the peculiar odor as from cynanche maligna. AVhen the eruption is tardy in making its appearance, the patient being depressed, Avith stupor or coma, Ave may place great dependence upon the action of an emetic. Or Avhen a retroces- sion of the eruption takes place, Avith the same symptoms, it is the most certain means of treatment, I prefer in these cases the acetous emetic, and give it so as to get a gradual influence upon the system, then carry it to thorough emesis. This may be followeel by the Aconite and Belladonna, and the sulphite of soda, as named above. To arrest the harassing cough that so frequently remains after the eruption has disappeared, I prefer either the infusion of clover hay, as before named, or the Tinct. e)f Drosera 5ss., to water §iv., a teaspoonful CATcry four hours. These remedies Avill be found much better than the ordinary cough medicines in use. SCARLATINA. This is essentially a disease of childhood, and feAV persons Avill take it after the age of tAventy. Unlike measles, it is also milder, as the patient is older. It is propagated by a specific contagion, either by inhaling the exhalations, or contact with the clothes of the patient. In some seasons it becomes epidemic; doubtless. because the poison is so intense as to be propagated readily and at a considerable distance, and the condition of the atmosphere SCARLATINA. 213 is favorable to the ready propagation of a zymotic disease. Scar- latina has been divided into three forms: S. Simplex, S. Angi- nosa, and S. Maligna, differing in their intensity, severity of symptoms and fatality. In some seasons the elisease will present the character of the first exclusively, in others it will be of the anginose form, and again every case will be malignant. Symptoms.—From six to eight days elapse after exposure be- fine the disease makes its appearance, and it is usually ushered in with a chill. In scarlatina simplex the chill is not very well marked, and lasts but a short time. The fever fallowing presents the common symptoms, increased heat of skin, arrest of secre- tiem, frequent pulse, loss of appetite, etc. In the course of from six te> tAventy-four hours, the eruption makes its appearance, in the shape e>f patches of efflorescence upon the face and neck, then extending te> the body. If the eruption is minutely ex- amined, it will he found te> consist of an infinite number of small reel points, the rose-colored ground being simply the base upon which they stand. Soreness of the throat, with slight difficulty of deglutition, appears at the commencement, though not usually severe, or accompanied with tumefaction. Fe>r eighteen to forty- ei«ht hours after the appearance of the eruption the fever con- tinues as before, but then rapidly abates, and in from three te> five days the redness disappears, and is followed by branny desquamation of the cuticle. In scarlatina anginosa, the chill is usually marked, there is nausea and vomiting, pain in the head and back, thirst, etc. The fever which follows is intense, the skin is dry, husky and burn- ing, the eyes dry and painful, the face congested and tumid, bowels constipated, urine is scanty, frequently voided and high- colored, with marked irritabillity of the nervous system. Sore- ness of the throat, with difficult deglutition, is complained of from the first, and on examination Ave find the fauces tumid and red, and the tonsils somewhat swollen. The nares are frequently implicated with the angina, and there is consequent stuffing of the nose, with difficult respiration and increased restlessness. The eruption sometimes makes its appearance during the latter part of the first day of the fever, but more frequently not until the second or third day; about the third or fourth day it has reached its liight. At the commencement there appears a slioht tumefaction of a portion of the surface, which gradually 214 DISEASES OF CHILDREN. assumes a scarlet color, and the minute red points are devel- oped. These patches increase in size until the greater portion of the surface is involved. During the eruption there is an ex- pression eff anxiety and suffering ; the child is restless and uneasy, and sleeplessness, Avhich resists the usual means of rest, is caused by the heat and stinging of the surface and soreness of the throat. The throat affection is here the most prominent feature; the soreness increases, the mucous membrane and subjacent tissue are engorged and tumid, and the secretion from the mucous follicles and salivary glands so viscid and tenacious as to cause great distress. In some cases, ulceration commences by the fifth or sixth day of the disease, and the secretion is difficult of re- moval and exceedingly offensive; occasionally the ulceration assumes a phagedenic form, and speedily terminates the life of the patient. Frequently enlargement of the cervical lymphatics commences from the third to the sixth day, and if not promptly treated, terminates in inflammation anel suppuration. The fever, under appropriate treatment, commences to abate when the erup- tion has made its appearance, and disappears entirely by the fourth or sixth day, Avhen desquamation commences. As this progresses the surface becomes paler, the epidermis exfoliating in whitish scales, or in large pieces when it is thick. Sometimes desquamation is retarded for tAvo or three weeks. Scarlatina maligna might be divided into tAvo kinds, the dis- tinctive symptoms being marked. In the one case there is marked evidence of prostration from the commencement. The chill is greatly prolonged, and the chilel seems dull anel stupid, the countenance vacant or besotted. Febrile reaction comes up slowly, the body becomes hot, the heat being pungent, but the extremities are colel. The pulse is frequent, but soft and fluent, or else small anel wiry. Frequently there is nausea and vomit- ing, sometimes diarrhoea. The tongue is broad, flabby, and cov- ered with afoul, dirty mucus, and the patient has difficulty in controlling its movements. The eruption makes its appearance slowly, the redness being more or less dusky. The throat affec- tion possesses the same characteristics; there is difficult degluti- tion and respiration, the mucous membrane presenting a duskv, tumid appearance. Ulceration is of frequent occurrence, their surfaces being foul, the edges ragged, and a strong tendency to phagedena. Enlargement of the cervical lymphatic glands is very common, with a tendency to the formation of a diffusive SCARLATINA. 215 abscess, and also, if the patient lives, to the formation of sec- ondary abscesses. As the disease progresses the symptoms are all of a typhoid character; there is the dark tongue, sordes on the teeth, feeble pulse, great oppression of the nervous system, tendency to diarrhoea, tympanitis, etc. In the second case, the disease exhibits but few, if any, pre- monitory symptoms. The child is attacked suddenly; the chill lasting but a quarter or half an hour, is not Avell marked, and is suceeedeel by the most intense febrile reaction. The skin is in- tensely hot, dry, and husky ; the mouth parched and dry; the eyes injected, dry, brilliant and painful. The patient is either delirious or suffers such intense pain as to be almost unconscious of Avhat passes around him. There is nausea and vomiting, the irritation being sometimes so intense that nothing can be retained on the stomach. In these cases the patient is frequently ex- hauste'd by the intense reaction, and dies before the appearance of the eruption, or during the time that nature is trying to throAV it on the surface. In the last tAvo forms of the disease, and sometimes in the simple form, Ave observe a want of poAver upon the part of the system to determine the eruption to the surface. In such case the skin appears tumid anel dusky, there is tendency to coldness e)f the extremities, and marked oppression of the nervous system. In such case, prompt measures must be taken to bring the eruption te> the surface, or the patient Avill die. Again, Ave observe cases in which the eruption comes out, but, from some cause, it retro- ceeles; in this case the same alarming symptoms manifest them- selves. In other cases, the anginose affection is so severe that it seems that the patient has not sufficient poAver to carry on respiration; sometimes the difficulty depends upon the secretion of a viscid, tenacious mucus. Diagnosis.—Scarlet fever is diagnosed from other diseases of the skin by the rose-colored efflorescence, upon Avhich are the innumerable small red points. A marked characteristic of the disease is the fact that the redness is effaced by pressure, and does not return for some little time. Thus, bv taking a pencil or the finger-nail Ave can write our name, which remains for a moment, and then gradually fades out. PuoeiNosis.—In the simple and anginose forms of the disease, the prognosis is favorable. In the malignant form, unless the 213 diseases of children. treatment is prompt and effective, the prognosis is unfavorable. In all cases, if the eruption becomes dusky, if coma or typho- mania ensue, or if the tongue becomes broAvn and foul, it is unfavorable. Sequelje.—Among the most frequent of the sequelae of scarlet fever, are diseases of the kidneys, consisting of simple exhaustion and Avant of poAver to secrete, chronic inflammation and albuminuria. In the first Ave notice a marked dullness anel hebetude, the appetite is poor, the boAvels irregular, marked debility and tendency to cachectic diseases, the blood being greatly impaired. In the second, the pulse is hard anel frequent, the dryness and huskiness of the skin continue, there is pain and soreness in the back anel loins, the appetite is poor, the tongue dry, whitish, and fissured. In the third, dropsy makes its appearance when the child is supposed to be convalescing. Continued disease of the throat, with irritation and enlargement of the cervical lymphatic glands, is sometimes observed. Ozae.ia, with Aveakness and irritation of the eyes, and chronic disease of the ears, attended by purulent discharge and partial deafness, is not unfrequent. Treatment.—In the treatment of this disease it is Avell to have some Avell-defined line of action—to determine exactly how Ave can benefit our patient. AVe knoAV, by experience, that the higher the fever, and the longer it continues before the appear- ance of the eruption, the greater the danger, and that the case also becomes critical in proportion to the amount of eruption and arrest of secretion. Thus, in all cases, it is good practice to use such means as Avill control the primary fever, anel favor the early appearance of the eruption. I have already mentioned, Avhen speaking of small-pox, that keeping the secretions free during this period lessened the amount of eruption ; this is the case here; hence depurants are advantageems. Care must be used, however, not to overstimulate either the skin, the kindeys, or the Imwels If the first, avc Avill have too free eruption, anel after- Avard inaction; if the kindeys, secretion may be arrested, or albu- minuria induced ; if the boAvels, it may cause retroe-ession of the eruption, or ATery great wrong of sympathetic innervation. Tn scarlatina simplex Ave put the patient upon the use e>f Tinct. of Aconite and Belladonna—the usual doses repeated every hour. The alkaline bath is used sufficiently often to keep SCARLATINA. 217 down the heat of the skin, and render it soft anel pliable. If the skin is inactive the bath may be hot; sponging the child with Avater as hot as can be borne, stimulates the capillary circulation, and brings the eruption to the surface. This may be done befbre the fire, covering the patient with a blanket, or it may be done under the bed-covering. It is Avell to say to the nurse, in these cases, " if the chilel complains e>f any part, sponge it with hot Avater, and cover with dry flannel." Generally Ave will find that these means relieve the irritation, the fever is lessened, and the eruption comes out early ; and con- tinuing these for tAvo or three days, there is but little fever after the eruption has made its appearance. The treatment for the throat will consist of the use of occa- sional inhalations of one part of vinegar to three of Avater, and a flannel wrung out df equal parts of vinegar anel water and ap- plied around the throat, with a dry flannel over it; this may bo changed every half hour or hour, anel as the disease subsides may be replaced with a dry flannel. In some cases no applica- tion to the throat is necessary, patients doing better Avithout it. In some Stillingia liniment may be used once a day. In scarlatina anginosa avc aelopt pretty much the same treat- ment. If the febrile reaction is high avc may add Veratrum to our sedative mixture, or Ave may substitute it for the Aconite. AVe de> not expect immediate sedation, indeed it is not desirable, but as the remeelies gradually influence the circulation, many of the unpleasant symptoms pass away. In some cases there will be marked irritation of the nervous system, with determination of blood to the brain. In these Ave replace the Belladonna Avith Gelseminum, continuing it until these symptoms have disappeared. In other cases there Avill be marked indications for Rhus, in the sharp stroke of the pulse, pain in the forehead, starting in the sleep, shrill cry, etc. This remedy is also indicated by burn- ino- of the surface1, Avith extreme nerArous irritation, anel Avhilst it fave)is the appearance of the eruption, it promotes functional activity e)f the skin. Apis will be inelicated by itching of the surface, anel pinkish coloration of the face. Baptisia Avill be suggested by the full face, se>meAvhat dusky, and by duskiness of the eruption. The disease eff the throat, which in this case is the most promi- nent feature, will demand much attention. The vinegar pack is 218 DISEASES OF CHILDREN. the best external application here, as it Avas in the preceding case, and should be continuously employed. The inhalation also offers the best local application to the affected mucous surface. The simple inhalation of the A'apor of Avater, or of water anel vinegar, or an infusion of hops, of German chamomile or garden tansy, will give great relief, and repeateel every two, three, or four hours, Avill be sufficient in many cases for the permanent cure. AVhen additional remedies are deemed necessary, they are best prepared in powder with gum arabic and sugar, and allowed to slowly dissolve upon the tongue. AVe may thus use chlorate of potash, hydrochlorate of ammonia, sulphite of soda, borax, alum, etc. Used in this way, they relieve dryness of the throat, anel the constant desire to SAvallenv, which is so unpleasant. If there is a marked tendency to enlargement of the lym- phatic glands, I administer Phytolacca, alternated with the rem- edies that have been named. It has been my experience that if remedies are carefully selected, Ave will have but little glandular trouble. Phytolacca is an excellent external application, or in place of this, especially if suppuration is threatened, a solution of salicylic acid and borax, aa. 5j. to Avater Oj. may be employed. Boracic acid in solution, oj- to Oj. of Avater, is also a good appli- cation. In the first case of scarlatina maligna, I employ Aconite anel Belladonna in the usual doses, using stimulant hot sponge-baths and the hot mustard fe>ot-bath, to aid in restoring an equal anel free circulation of blood. The indications for remedies are care- fully noted. Baptisia is frequently inelicated by duskiness of the skin and even of mucous membranes; Rhus by the sharp stroke of the pulse, starting in sleep, and contraction about the base of the brain; Phytolacca by the soreness of mouth and SAvelling of the cervical lymphatics; Ipecacuanha by irritation of the stomach and diarrhoea ; Nux bv the nausea and vomiting, associated Avith nervous prostration, etc. As typhoid symptoms rapidly develop, Ave select our anti-zy- motic early, sometimes commencing its use at our first visit. The pallid, dirty tongue (not a common case) is met by sulphite of soda ; the reel tongue, Avith glutinous dirty coat, calls for sul- phurous acid. The latter remedy is inelicated in a large number of e:ases, and is not only one of the best for internal administra- tion, bnt also as a topical application to the throat. In severe cases it may be used Avith a spray apparatus. ISIuriatic acid may SCARLATINA. 219 be added to the child's drink Avhen the indication is strong— the deep red tongue. Baptisia has already been named, the in- dications being dusky coloration of face, surface, tongue, and throat Chlorate of potash is indicated by the peculiar fetor, as from cynanche maligna, and may iioav be used as an internal remedy, as a gargle, or as a spray. The throat receives the same treatment as the preceding case with the addition of an infusion of Baptisia tinctoria as a gargle, if it can be used in that Avay; if not, by a spray instrument, or by inhalation of the vapor. I would also give it internally, a teaspoonful every two or three hours. If the throat is tumid and dusky, or is ulcerated and sloughy, boracic acid or thymol in solution Avill be found an excellent application. The sulphu- rous acid, one part to four of Avater, is also very good Avhen used Avith the spray apparatus. In very severe cases, Avhen there is marked torpor of the nervous system, with rapidly approaching coma, I prefer to commence the treatment with an emetic. I use the acetous tincture of Lobelia and Sanguinaria, and give it so as to obtain a prompt anel thorough action. It should relieve the depression of the nervous system, anel produce a free and equal circulation of blood. If the eruption should not appear at the usual time, the symptoms becoming grave as named, I should also use the emetic, as I Avould if there Avas a retrocession of the eruption. In this, as well as the other forms of scarlatina, in some cases, I prefer fatty inunction to the use of the bath. It relieves the irritation of the skin, keeps it soft, anel thus favors some se- cretion. Many physicians direct their patients rubbed with a bacon rind. A prominent Homoeopath of my acquaintance places much dependence upon it. Instead of this I use lard alone in the first forms e>f the disease, and an ammonia inunction (hyd. ammonia 5j, bird 5ij.) in the malignant form. In congestive diseases it has been recommended to sponge the surf ice with a solution of carbonate of ammonia, or liqimr am- monia. Several cases are recorded of malignant scarlet fever, purpura hemorrhagica, and typhus fever, in which it was em- plovcd with advantage. In using it, one ounce of muriate of ammonia is added to two quarts of hot Avater, and applied freely. The carbonate may be used in the same proportion in diseases of children. 220 DISEASES OF CHILDREN. It must not be forgotten that this, like other eliseases, will vary in different years. In one season fatty inunction is one of our most important means, and water seems to exert an unpleas- ant influence upon the skin. But in another year, the fatty matter can not be used, for it seems te> close the skin up anel pre- vent excretion, and Ave are forced te> use soap anel Avater for its removal, and afterwards employ baths. I have had most admi- rable results from hot sponge baths, as I have had from the ammonia just named. I may also ne>te that tincture of muriate of iron has also been used in scarlet fever with advantage. It is given after the erup- tion has made its appearance; the combination Avith glycerine is the best form, and this may also be used as a gargle. It Avill also be of advantage during coiwalescence, and Avill tend to prevent dropsy and the other sequelae. The enlargement of the lymphatic glands is a source of much trouble in this form of the disease, appearing frequently when the patient is apparently convalescent, I prefer an application of the Salicylic Acid and Borax aa. 5ss., to Avater Oj., or some- times double this strength.. If it becomes evident that suppura- tion Avill occur, no benefit Avill folloAV from trying to keep it back; indeed Ave would thus endanger diffusive abscess. Te) hasten suppuration, Ave apply a poultice of a decoction of cornus, thickened Avith Avheat bran or poAArdered ulmus, or of equal parts of hydrastis and elm. It is Avell to continue the use of the salicylic aciel solution with the poultices, as a preventive against diffusive abscesses and purulent absorption. And should there be symptoms indicating this result, put the patient upon the use of sulphite of soda, and give quinine and iron, with stimulants, if needed, and a nutri- tious diet. If the lymphatic inflammation goes on to suppurotian, it is Avell to open the abscess early, and not let the pus burroAV in the tissue. This not only relieves pain, but it lessens the danger of secondary abscesses. The first intimation of dropsy should be noticed, and appro- priate treatment adopted. Usually Ave will note its appearance in a swelling of .the upper eyelids, and sometimes in a night the eyes will be closed. (Edema of the feet is also common, and in either case albumen will probably be found in the urine. In the PERTUSSIS. 221 majority of cases Apocynum, with the small dose of Aconite, Avill be the remedy. If not, we will probably choose betAveen Aralia anel sulphate of manganese. PERTUSSIS-AVHOOPING-COUGH. This is eminently a contagious affection, though Iioav it is propagated is more than is knoAvn. Usually it is contracted only Avhen children are brought in such immediate proximity that the breath or exhalations of the diseased person are inhaled; this, however, is not always the case, as the poison seems to contami- nate the atmosphere, so that persons take it when at considerable distance from those1 having it. It is uiide>ubtcdly a disease of the nervous system, the parts implicated being the pneumogastric nerve and medulla oblongata at its origin. Anel yet, post-mortem examination has not sIioavii any more serious lesiem e)f the medulla than evidence of deter- mination of blood, which Ave Avould be likely te) find in any case of sue-h prolemged irritation of the parts' to Avhich the nerve is distributed. Like other contagious diseases, it runs a very regu- lar cenirse, anel gives immunity against a subsequent attack. Symptoms.—AVhooping-cough manifests itself at first as a simple catarrh, the cough being gradually developed. Some days elapse before there is anything distinctive in it; and it is not usually Avell marked under from tAvo to four Aveeks. The couoh differs from others in that it seems to arise from an oh- struction to respiration, anel forcible inspiration is taken, and then there is a series of short expulsions until the air is all ex- pelled. The tendency to cough still continuing, produces great distress, anel more or less evielences of impaired respiration are noticed. The whoop is developed Avhen the cough becomes in- tense, and is the shrill sound formed as the air is draAvn through the yet contracted larynx in the fo- -ible inspiration succeeding the couo-h. The cough is paroxysmal, the paroxysms recurring at longer or shorter intervals, in proportion to the severity of the disease. There is a secretion of glairy mucus in most cases, which is raised at the latter part of the cough, and frequently seems to increase the suffering. If the disease is very severe, and some- times when mild, there is a free yellowish expectoration. There 222 DISEASES OF CHILDREN. is frequently some fever at the commencement of the disease, and it may occur during its progress. AVriters divide pertussis into three stages : the first, lasting from five to fifteen days, presents the symptoms of ordinary ca- tarrh ; the second, lasting from three to six Aveeks, presents the peculiar whoop, which gives name to the cough ; anel the third, of variable duration, is the period of decline. It is during the second stage of the disease that the symptoms become so aggravated as to demand relief. We sometimes see the paroxysms of cough so severe that the little patient will turn purple in the face, gasp for breath, and even for some time after- Avard exhibit marked evidences of imperfect respiration. Occa- sionally bronchitis sets in and is very troublesome; sometimes there is marked congestion of the lungs; at others, the frequent and severe paroxysms of coughing prevent necessary rest, derange the functions of the body, and wear the patient out. In some cases there is a tendency in the disease to recur for months after it has ceased, on exposure to cold, though almost always in a mild form. Instead of impairing the strength of the lungs in feeble children, it seems rather to have increased it, and may sometimes be regarded as of marked advantage to the child. Diagnosis.—In the first stage it is with difficulty recognized, but in the second, the paroxysmal character of the cough, its long continuance Avithout seeming cause, and the peculiar Avhoop, are sufficient for the diagnosis. Treatment.—Except in some rare cases I discard all of the old methods in the treatment of this disease, and rely wholly on specific means. We get a clear idea of the variability of named diseases in this study, because it belongs to the class of conta- gions diseases, is produced by a specific poison, and has symp- toms so characteristic that it cannot be mistaken, and to the cas- ual observer all cases are alike except as to severity. Yet Ave find that it is not ahvays the same disease, but varies from season to season, and the remedy that cures it uoav may be of no service in the next recurrence of the disease. If one will but think, it is just the same with other coughs. AVe have a group of remedies for whooping cough, all of them good, all of them specific, if Ave have the right indication. They are Nitric Acid, Belladonna, Drosera, Bromide of Ammonium. PAROTITIS. 223 Nitric Acid is an old remedy, and a very good one, but will not benefit all cases of whooping cough—which are the cases? If the tongue has a violet color, showing over red, the remedy Avill cure whooping cough, as it Avould cure ague, or any other curable disease, with the same symptom. Belladonna is also an old remedy, and a most excellent one, but it Avould not relieve the nitric acid cases. AVhat cases \vi 11 it cure ? AVhen the patient is dull and inclined to sleep, (the eyes are dull, the pupils dilated,) just as it is the remedy in other diseases shoAving these symptoms. Drosera is the remedy for the cough of measles. There is something peculiar about this cough Avhich Avill be readily rec- ognized, and it is based upon a peculiar catarrhal condition of the mucous membranes. AVhooping-cough may sIioav these very conditions, and if so, Drosera is the remedy. Bromide of Ammonium is peculiarly the epileptic remedy, and if our whooping-cough shoAvs the peculiar convulsive condition, Ave expect to relieve with this agent. AVhat may Ave say then ? Why certainly that Ave haATe four classes of Avhooping-coughs, distinct and separate, and Avhich may be diagnosed, and the right remedy selected. PAROTITIS. Parotitis, or mumps, belongs to the class of diseases we have been studying, as it is caused by a specific contagion, generateel during the progress of the disease, propagated by contact, and Avhen a person has had the disease there is subsequent immunity. In the case of small-pox the contagious material is something tangible : in scarlatina and rubeola there is a distinctive disease of the skin, and may be such change that it is propagated by the epidermis throAvn off, or by the excreta in breath, from skin, kidneys and boAvels. But in Avhooping-cough and in mumps we do not know the character of the contagion, or why in the one case it should involve the medulla oblongata, and in the other case the parotid glands. Pathology'.—Arising from a specific contagion, to avImc'i the patient has been exposed, usually by contact, Ave find the disease manifesting itself in a peculiar inflammation of the parotid gland. I say peculiar, because there is but little exudation of plastic 224 DISEASES OF CHILDREN. material, anel but little tendency to suppuration. In some case-, indeed, it seems but little more than an irritation with markeel determination of bhmd, with some watery or serous effusion into the tissues. In other cases the inflammatory symptoms are all Avell developed, and the function of the gland entirely suspended. Other glandular tissues may be involved. Thus we have a me- tastasis of the disease te> the testes in the male, and to the mam- mary glands in the female, and I have noticed disease of the thyroid, and I think of the thymus bodies. Symptoms.—The period of incubation varies from five to twelve days, during Avhich the person has no symptom of the coming trouble. Frequently he Avill ge> to bed well, ami aAvake with SAvelling about the jaAvs anel ears, stiffness e>f the neck,'anel when he sits doAvn to his breakfast Avill finel both mastication and deglutition difficult. Acids increase the pain, anel a very common domestic means of diagnosis is to have the patient try to eat a pickle, when the sharp pain about the articulation of the jaAv soon tells the story. In some cases the disease will be ushered in with headache anel pains in the back and extremities, a avcII marked chill, followed by febrile reaction In these cases the inflammatory actiem runs high and the pain in and about the parotid space anel ear is ex- quisite, and the patient can hardly eat or speak because it in- creases it. The fever Avill continue one or twe) days, and then pass away Avith increased excretion, but the parotial inflamma- tion and swelling Avill continue for five or *six days, and then sIoavIv pass aAvay. But one side may be involved in the attack, and it is thus claimed that the person may contract the disease again on subse- quent exposure, the other parotid being involved. AVhen there is a metastasis to the testes, the patient feels a deep aching dragging pain, with occasional lancinating pains through theiorgan. The slightest touch or pressure occasions exquisite pain. The testicle is found greatly SAVollen and red- dened; very rarely both are affected at a time, but occasionally one is involved, and as the acute symptoms subside, the other testicle swells and becomes tender. In these cases the fever is likely to recur, and the secretions are arrested. Mastitis is not so common, yet I have seen cases in which the breast Avas very sensitive and painful. The thyroid enlargement SCROFULA. 225 is associated with ovarian irritation in the woman after puberty, and may continue for some months. Treatment.—The patient is put upon the use of Aconite or Veratrum, as indicated, with Phytolacca as the specific remedy in the larger number of cases. A very common prescription is, Py Tinct. Aconite gtt. v., Tinct. Phytolacca gtt. x., water 5iv.; a teaspoonful every hour. Belladonna replaces the Phytolacca, if there is dullness and stupor; Rhus, if there is sharp pain, frontal headache, and sharp pulse; Gelseminum, if there is in- creased heat of the head, inability to sleep, with general head- ache. In some cases there is a clear indication for sulphurous acid in the red tongue, Avith nasty glutinous coating; and in others the indication is equally clear for sulphite of soda. I do not think it best to make local applications to the savoI- len parotids—a flannel cloth tied around the head to insure Avarmth being sufficient. Still, if the pain is very severe, a lotion of—R> Tinct. Aconite oj. Tinct. Phytolacca .Sj., Avater 5j., may be applied every tAvo or three hours. Sometimes a flannel cloth Avrung out of hot water, and applied for a few hours, will give relief. If there is a metastasis to the testes, they should be Avell sup- ported Avith a flannel bandage, and in some cases the lotion of Aconite and Phytolacca may be used, and in others of Bella- donna and Phytolacca. In older persems, if the SAvelling per- sists, Ave strap the SAArollen testicle firmly to the abdominal Avail, using adhesive plaster. SCROFULA. Scrofula, or king's evil, is one of the most common diseases the physician has to treat; and manifesting itself in so many differ- ent forms, its symptoms are protean, and its treatment varied and difficult. It is undoubtedly a disease of the blood, though the secretions and nervous system are markedly affected. Cope- land remarks that " The blood in scrofula and tubercles has long been considered popularly, and with much truth, to be of a poorer quality than in healthy constitutions." Simon states that the blood is deficient in solid constituents, especially in fibrin and in corpuscles. According to Duboise, the ble>od of scrofulous subjects coagulates slowly, the clot is small, soft, anel diffluent; the serum is thin, and often of a reddish color. Under 15 226 DISEASES OF CHILDREN. the microscope, some of the corpuscles appear devoid of color at the edges only, some entirely colorless. Their size is not mate- rially changed, but they appear flattened, spherical, or cylindri- cal. Hence he infers that there is a deficiency e)f the salts in the blood of scrofulous persons. Mr. Phillips remarks that, in every case in which he examined the blood of scrofulous subjects, the coagulum Avas relatively small, the serum large, the clot un- usually soft, almost diffluent; in a few instances only, it was tol- erably firm. In most cases the proportion of globules Avas con- siderably under the healthy standard. The fibrin had not gen- erally undergone much change. The causes of scrofula, whether those acting on the parent, or the individual himself at a very early age, or even at later periods, Avhether external or internal, Avhether hereditary, congenital, or acquired, have all a similar tendency, namely, directly to depress, or to exhaust organic ner- vous, or vital poAver ; and thereby to impair vital resistance, to preArent the processes of repair consequent upon morbid vascular action, and to arrest the formative or organizing tendency of the exudations produced by this action. Not only is there a dispo- sition to a dyscrasia—to a solution of vital cohesion, observable in parts near the seat of scrofulosis, but there is also an absence of the formative effort in the fluids exuded by morbid actions in scrofulous constitutions. The state of vital poAver or endoAvment in the several tissues or organs of scrofulous persons, appears in- sufficient both for the healthy or sthenic actions or functions these parts should perform, and for the organization of the fluids or matters effused from their vessels. Hence the changes Avhich the exuded matters undergo neither favor nor are folloAved by organization, even in its loAvest grades; and most probably, the fluid itself is exuded from the capillaries of a kind and in a state which indisposes it to organization. Scrofula is said to be hereditary, and so it is in this, tmat the child inherits a defective vitality, which manifests itself in im- perfect elaboration of the blood, and enfeebled vitality of tissues and organs. Such persons may live for years Avithout any man- ifestations of the disease, simply because there has been no cause acting to further depress vitality, or to determine scrofulous de- posit. Finally, howe\rer, from arrest of secretion or other cause, the system is depressed, and an irritation of some part being set up at the same time, Ave have full manifestatipn of the disease. If Ave have correctly stated the pathology of the disease, what SCROFULA. 227 measures may be adopted to remove this predisposition? Some contend that it can not be removed, but we have evidence suffi- cient to show that it can be entirely eradicated. To accomplish this Ave resort principally to hygienic measures, such as will stim- ulate healthy digestion, secretion, and innervation. Remove the child to the country, let it have plenty of out-door exercise with accompanying light and sunshine, give it nutritious food and es- cheAv condiments, pastry, and SAveetmeats, and the entire consti- tution of the chilel Avill undergo a change. Scrofula manifests itself in various ways; very frequently the deposit commences in the lymphatic glands; sometimes in the viscera, as of the lungs, liver, brain, etc.; again in the bones, in the muscles, in the skin, in fact in all the tissues of the bod v. The determining cause of the deposit is undoubtedly an irrita- tation of the part, causing determination of blood. Symptoms.—The symptoms of a scrofulous constitution are not well marked, though it has been frequently described as if they Avere. It is true that it occurs most frequently in children of fair skin, blue eyes, light hair, anel regular features; but it is so often met with in persons of dark skin, hair and eyes, irregu- lar features, and rough development, that it is impossible to sav, by a child's appearance, Avhether it is scrofulous or not. There is, hoAvever, in very many cases, such manifest imperfections in assimilation, circulation, and nutrition, and feeble vitality, that Ave are enabled to recognize the scrofulous constitution. Usu- ally, the previous history of the family Avill throAV some light on the matter; but, as Prof. Powell has Avell demonstrated, the scrofulous constitution may be and often is developed in children by incompatibility of the parents. Scrofula manifests itself when, from any cause, the vitality of the system is so depressed that the blooel is not properly elabo- rated, or the detritus of the system is not removed, either by an imperfection in the process of retrograde metamorphosis, or by failure of the excretory organs. The situation is determined in all cases by the existence of a local irritation or inflammation in or adjacent to the parts affected. Thus, Ave observe scrofulous deposit anel disease of the cervical lymphatic glands, from elisease or irritation of the mouth or throat; involvement of the axillary "•lands, from disease of the arm or breast; of the inguinal glands from disease of the loAver extremities or genital organs; of the 228 diseases of children. mesenteric glands, from disease of the bowels; of the lungs, from irritation produced by cold ; anel in the muscles anel bones, from the same cause. It might be divideel inte) tAVe> fetrms, as it occurs in the lymphatic glands, or as a eleposit in the fe>nn of tubercles in the structure of a part, but no practical benefit would grow out of such distinction. As avc have, in other places, de- scribed scrofulous or tubercular affections of the principal organs, Ave will confine ourselves here to a description of it as it affects the lymphatic glands. In many cases the irritation giving rise to the development of scrofula is very manifest, and occasionally demands treatment, but in others it is very slight. The superficial lymphatic glands are then observed to become slightly enlarged and hard, so as to be very perceptible when the finger is passed over them. This occurs frequently in scrofulous children in the superficial cervical glands, without further development, and is considered by many as the best indication of a scrofulous constitution. AVhen the disease has fully commenced, one or more of the glands con- tinue to enlarge, a Ioav form of inflammation sets in, and deposit takes place in the adjacent tissues, which become swollen anel hard. Noav the inflammation becomes more or less acute, the part is reddened, painful, hot, tender on pressure, and the swell- ing increases rapidly. Continuing in this way for a longer or shorter time, suppuration commences, and the deposit is gradu- ally changed into pus, which in time makes its Avay to the sur- face, and is discharged. This occupies a variable period of time, sometimes passing through all its stages in eight or ten days, and at others occupying as many weeks. In some cases the inflam- mation is acute and the pain severe, but in others it progresses Avithout much redness, heat, or pain. The pus forms sloAvly in many cases, and there is but little tendency to its discharge, anel in others weeks pass over, the part still continuing hard ; and at last, when our patience is nearlv exhausted, suppuration occurs rapidly. Sometimes the pus is Avell formed and healthy, and Avhen discharged the part heals readily; but at others it is watery, of a greenish-broAvn color, or clear, Avith more or less flocculent material mixed with it, Occa- sionally the abscess exhibits no tendency to point, but the pus burroAvs in the tissues for a long time, unless it is opened. In other cases, Avhen the pus is discharged the abscess does not heal, but continues to discharge a dirty, flocculent pus; and if we ex- SCROFULA. 229 amine it, Ave will -find the Avails ragged, and often a chain of lym- phatic glands dissected out, and lying at the bottom. The constitutional disturbance varies greatly. Sometimes there is quite brisk febrile action when inflammation first comes up, with le>ss of appetite, arrest of secretion, and much pn>stra- tion. In these cases, suppuration is frequently marked with a chill or rigor, and occasionally attended with hectic fever and night-sweats. In other cases, there is no constitutional disturb- ance further than loss of strength, anel some derangement of se- cretion, languor, and a peculiar pallid appearance of the surface. Diagnosis.—Scrofulous enlargement is readily recognized from its situation, anel from the attendant symptoms above named. Prognosis.— In very many cases the prognosis will be favor- able, as the tendency to the disease is not so strong but that it may be removed by appropriate treatment, and measures calcu- lateel te> improve the general health. There is no doubt but that by proper care the constitution of a child can be so entirely changed, in the course of time, that the tendency to this disease Avill be entirely removed. There are other cases, hoAvever, in which, though Ave may get the patients safely through the present attack, they will inevitably die, sooner or later, of this or some analogous affection. Treatment.—When children are predisposed to scrofula, a judicious hygienic plan should be adopted to strengthen the constitution, by improving the functions of digestion, assimila- tion and nutrition. Such children are said to be tender, ami hence they are kept in the house a considerable part of the time for fear of colds and sickness, and being weakly they are petted, and their appetites pampered; and not spending their time in play, as they should de), their minds are precociously developed at the expense e>f their bodies. Instead of this, such children should be accustomed to the open air from an early age. As with plants, the human species can not be robust and stout without fresh air and sunshine. As soon as they commence walking they should plav in the open air whenever the weather is suitable. In this Avay, the constitution is strengthened, anel the liability te> e-olels by alternations of temperature much reduced. Sleeping- rooms should in all cases be large, well-ventilated, and exposed to the direct rays of the sun during some portions of the day. 230 diseases of children. Up to the age of eight or ten years, the child's occupation should be out of doors, and Avhether it Avas play or Avork, it should be of such a character as to bring into action all the muscles of the boely. Before this age the child should not be required to study, neither should it be sent to school, there being sufficient time after this for all laudable educational purposes. Regular meals e>f goe>d, hearty food, with fruits in their season, with a sedulous avoidance of all cakes, SAveetmeats, etc., are of the highest im- portance. An observance of these rules, the children being raised in the country, Avill almost invariably result in a complete change of constitution, and such increased vitality that not only is the predisposition to this disease removed, but the child becomes a vigorous, hearty man or Avoman, instead of dropping into a premature grave from phthisis or some kindred affection. In the treatment of the disease, the indications are to, first, improve the quality of the blood, and raise it above the point at Avhich scrofulous material is effused, and, second, to promote the absorption and elimination of such material as may have been deposited. To accomplish these indications various means are resorted to, according to the condition of the patient. Altera- tives are relied upon to a very great extent, and various agents of this class are employed. By some the compound syrup of Stillingia and iodide of potassium are considered the preferable agents, anel are used to a very great extent. My ex- perience has not been favorable to these remedies, and I have been compelled to select others. I uoav use the Phytolacca, Rumex Crispus, Alnus Serrulata, Iris, Scrophularia, Podophyl- lum, Corydalis, and some tAvo or three other agents, sometimes singly, or two or three combined to suit the indications of the case. Acetate of potash or other saline diuretic is my main dependence te> promote absorption and elimination by the kid- neys. I believe it to be as much more efficient than iodide of potassium, as this is over epsom salts ; at the same time employ- ing the bitter tonics, iron, the hypophosphites, and cod-liver oil. Very much depends upon getting proper action of the three principal emunctorie.s—the skin, kidneys, and bowels. Great care is necessary, hoAvever, in the severer cases, not to overstimu- late and exhaust these organs. To restore the secretion of the skin, I employ—if it is dry and husky—oleaginous frictions, followed by thorough washing Avith castile soap and water; if soft, relaxed, and flabby, I use the bitter tonic baths; if there is SCROFULA. 231 deficient capillary circulation, Avith coldness of the extremities, a sponge-bath of dilute Tinct of Capsicum. As a local application to promote resolution, I have used equal parts of tinctures of Belladonna and Stramonium, and glycerine, or if there is much fever, an equal part of tincture of Aconite. In other cases, a wash e>f equal parts of tincture of muriate e>f iron anel glycerine may be used, or the part may be painted with the iron, and then followed by the lotion named. In some cases we obtain gooel results from the use of the Mayer's ointment or the black salve. Finely pulverized Indian turnip, made into a poultice, is an excellent application. If there is much heat and redness, Ave ma use fomentations of Stramonium leaves, or a poultice of a de. 'tion of Cornus and wheat-bran. If it is seen that resedution . .'not be effected, Ave will employ poultices to facilitate suppuration, and if pus has fen-med to any extent, in- stead of permitting it to burroAV, Ave will immediately open the abscess. The poultice may be continued fe>r a feAV days longer, until the inflammation has passed off, Avhen it may be elressed with Mayer's ointment, or other stimulant application, until it heals. If it does not discharge Avell, anel looks ragged, it Avill be best to use a solution of sesquicarbonate of potash until sup- puration becomes free. And in those cases in Avhich the healing process is sIoav, and the discharge thin and Avatery, it may also be employed Avith advantage. In some cases the healing process progresses until the abscess is nearly closed, but a reel, ugly cicatrix is left, from which there is more or less oozing; or, if it closes, it breaks out frequently, and, after running for a feAV days, again closes, with a thin, blu- ish cicatrix. These cases are remarkably tediems, and are \rery difficult to cure. I have treated them by employing the zinc paste to entirely destroy the morbid cicatrix, and then healing with some mild stimulating ointment; or, instead of this, Ave may sometimes dissect the cicatrix out, and draAV the parts together with adhesive straps. In other cases Ave will find that a decoc- tion of equal parts of Cornus, Rumex, and Alnus, continually applied, and taken internally, Avill in time overcome the disease. 232 diseases of children. DYSCRASIAS. The definition of dyscrasia by Dunglison, " a bad habit of body," Avould ansAver our purpose very well as describing a bad blood and an impairment of nutrition, and from this enfeebled tissues. The older pathologists useel the term to express " an ill habit or state of the humors," i. e., of the fluids of the body. It is used to describe a condition of life, and not a special form of diseased action, though whatever form this may assume, it possesses the characteristics of the entire group. In scrofula the impairment of the blood manifests itself in the deposit of imper- fect albumen, most frequently in the neighbor! od of lymphatic glands. In this the nutritive fluids are impai , and the tissues formed from them are also imperfect. In acu .tion to this the excretory organs being insufficient for its removal, Ave have it throAvn off in the skin, producing skin diseases; in cellular tissue, producing Ioav grades of inflammation, and in other tissues giving rise to degenerations and inflammatory affections. Causes.—The causes giving rise to this condition are numer- ous ; indeed Avhatever depresses the vital poAvers, either an im- pairment of digestion and assimilation, or retrograde metamor- phosis and excretion, will produce it. Hereditary feebleness of vitality or formative power is very frequently the cause. Aeld to this imperfect food, deficient ventilation, impure air, Avant of sunshine and exercise, and we have the common causes. AVe have also to take into consideration the fact that bad blood or bad tissue manifests a constant tendency to reproduce itself— indeed, that Avhenever a fluid or tissue has had its vitality thus impaired, it perpetuates the impairment; also, that every point where the disease manifests itself becomes, to a greater or less extent, a depot of supply or depravation. Thus the fluids are being constantly impaired by materials taken into them from these sources. In some of these cases, the lymphatics suffer more than other parts, and the lymph being impaired, the blood which is formed from it is impaired to the same extent. Symptoms.—The evidence of bad blood and bad tissue may be found in the general impairment of function, as Avell as in the many local diseases arising from it. Nutrition being imperfect, DYSCRASIAS. 233 the tissues are soft, and have lost their tone and elasticity ; the circulation is feeble and unequal ; the appetite is variable, and the digestive act imperfect; the tongue being pale, broad, and frequently covered with a pasty Avhite coat. There is a Avant of activity of the excretory organs. The skin is dry, rough, and harsh, or soft and flabby, in neither case per- forming its function Avell. The urine is changed, containing the triple phosphates or urates, or at times of low specific gravity and deficient in urea ; while the boAvels are irregular, neither acting Avell as a digestive or an excretory apparatus. The local diseases \Tary in character, but they are alike in giving rise to deterioration of structure, low grades of inflam- mation, a poor, purulent product, and deficient power of repair. Treatment.—The indications for treatment are very plain in these cases. AVe have to get rid of the imperfect blood and im- perfect tissues, anel replace them Avith good blood and good tissue. AVe get rid of the bael material by increasing the process of retrograde metamorphosis, anel stimulating the excretory organs—the skin, the kidneys, anel the boAvels. AVe obtain better blood and better tissue by the use of means that improve the appetite and digestion, anel that restore to the blood the materials in which it is deficient, and Avhich stimulate the nutri- tive processes. The selection of remedies to accomplish these objects is not ahvays easy. The processes that Ave desire to act upon are vital processes, and remeelies that increase their activity, if properly used, may depress them, or even arrest them, if used Avithout care. Excretion, or the removal of the bad blood or tissue by the skin, kidneys, and boAvels, occupies the first place. Usually \\;e Avill have no trouble in obtaining this influence, if Ave are willing to give time enough, and employ simple agents in small doses. I prefer the vegetable alteratives in infusion, singly, or tAvo or three in combination. The Alnus, Rumex, and Scrophularia are favorites of mine, and I think they Avill give satisfaction. The skin is reached by the use of baths and frictions. If dry and harsh I prefer fatty inunction, Avith brisk friction, occasion- ally using a small portion of quinine in this Avay, if there seems need for its tonic influence upon the nervous system. If relaxed and flabby, stimulant, tonic, or astringent baths are the best. If the boAvels are inactive, minute doses of Podophyllin, 234 diseases of children. thoroughly triturated with sugar, ansAver a very good purpose, but the doses should be so small as not to produce purgation. The kidneys are called into actiem by the use of acetate of potash, better than by other remedies, the solids of the urine being especially increaseel. I have regarded this as our most poAverful alterative with children, being much better than the iodides in such common use. AVhile employing these means the patient is put upon the use of iron, the hypophosphites. cod oil, and the bitter tonics In many cases the tincture of muriate of iron with glycerine, as heretofore named, Avill ansAver the purpose ; or if a stomachic is needed, a small portion of tincture of Nux vomica or solution of strychnine may be added. Of course a nutritious diet, carefully adapted to the condition of the patient is indispensable, and the selection of this and its preparation, will require the advice of the physician. Add to this good ventilation of and sunlight in the sleeping apartments, and out-door exercise, attention being paid to warmth and clean- liness, and Ave ha\Te an excellent treatment. INFANTILE SYPHILIS. A child may receive the primary disease from a chancre of the breast, while nursing, or from a chancre of the lips in the act of kissing, or by the use of cloths or clothing soiled by the dis- charges from a chancre. Though examples of each of tuese are upon record, they are of very rare occurrence. In my practice I have seen one chancre of the breast, Avhich, had the woman been nursing, would have communicated the disease to the child, and I have seen three cases of chancre of the lip, in one of which such transmission occurred. In such cases, the presence of the specific sore will be sufficient for the diagnosis, if the physician giA'es it a close examination. All the symptoms of the primary disease Avill be there, anel after a period varying from tAvo months to a year, constitutional symptoms Avill be observed, if the system becomes infected. But Ave have a more common source of the syphilitic lesion, in the transmission of the disease from one or the other of the parents to the chilel in utero.- This is hereditary syphilis, and is the femn Ave desire to study particularly. INFANTILE SYPHILIS. 235 Secondary syphilis may be transmitted by either parent to the child, which will be born impregnated by the poison. The fol- loAving are the propositions laid doAvn by M. Ricord regarding its transmission, and they may be received as facts well established : " 1. The father and mother may transmit the disease to their child indifferently, if either e>r both of them be affected. " 2. Transmission may occur from the parents to the child, Avhen they are affected with constitutional symptoms, or Avhen a concealed syphilitic diathesis exists in them. " 3. The absence or existence of constitutional symptoms in parents at the moment of impregnation and conception exerts no influence on the form of the disease, Avhich may afterward appear in the child. The distinction established by M. Cazenave be- tAveen congenital and hereditary syphilis, and which is based on the absence of constitutional symptoms in the parents at the moment of generation, or Avhich have been developed in the mother during gestation, is totally erroneous; and indeed M. Cazenave confesses that his opportunities of observing have not been ample. " 4. The character and period of the manifestation of the symptom in the child are governed by the stage to Avhich the elisease had advanced in the parents at the moment of generation. The treatment to Avhich the parents Avere subjected may also re- tard, prevent, or modify its appearance in the child. " 5. If the parents are both healthy at the time of generation, and the mother contracts syphilis during gestation, she may transmit the disease to her child. Of this I have seen several examples at various periods of pregnancy, even to the seventh month inclusive. " 6. When the venereal poison is transmitted from the mother to the child during pregnane-y, infection takes place through the medium of the placenta, anel in this case appears to occur after the fourth month of utero-gestation. " If the father alone be diseased at the moment of generation, an abortion may occur at any period of pregnancy. If the mother alone be diseased at the time of conception, the abortion Avill not take place until after the fourth month. " 7. Children born of a father and mother affected Avith syphilis may escape infection ; for a certain disposition to receive con- stitutional disease is necessary for the child as Avell as the adult, and this may be absent. 236 DISEASES OF CHILDREN. " 8. Observations made as accurately as possible seem to prove that constitutional syphilis may be transmitted from the child to the mother during utero-gestation." Symptoms.—The most common, as Avell as the most reliable, evidence of hereditary syphilis, after the child has attained the age often years, is the peculiar appearance presented by the per- manent teeth, especially the upper incisors. These are usually short and narrow, with a broad vertical notch in their edges, and their corners rounded off. Horizontal notches or furroAvs are often seen, but they as a rule have nothing to do Avith syphilis. Associated Avith this condition of the teeth, anel earlier as to time, being noticed by the end of the first year, are the following symptoms : "The skin is almost ahvays thick, pasty, and opaque. It often shoAvs little pits or scars, the relics of a former eruption, and at the angles of the mouth are radiating linear scars, run- ning out into the cheeks. The bridge of the nose is almost always broader than usual, and Ioav ; often it is remarkably sunk and expanded. The forehead is usually large and protuberant in the regions of the frontal eminence ; often there is a Avell marked, broad depression a little above the eye-broAvs. The hair is usually thin and dry, and uoav and then (but only rarely) the nails are broken and splitting into layers. If the eyes have already suffered, a hazy state of the corneae, and a peculiar leaden, lusterless condition of the irides, with or without synechiae, may be expected. If, howevTer, the eyes have not yet been attacked by a syphilitic inflammation, they Avill present no deviation from the state of perfect health and brilliancy. " The occurrence of Avell characterized intestinal keratitis is iioav considered by se\-eral high authorities as pathognomonic of inherited taint. It is also invariably coincident Avith the syphi- litic type of teeth; and Avhen the tAvo conditions are found to- gether in the same individual, I should certainly feel that the diagnosis was beyond doubt."—Hutchinson. The symptoms present at birth or occurring during infancy vary in different cases. In some cases the child is born shriveled and emaciated, the skin hanging in folds in different parts of the body The throat is sore, the voice rough and unnatural, and an unnatural discharge is noticed from the nose. Associated with this may be a pustular or squamous skin disease, and INFANTILE SYPHILIS. 2?7 copper-colored discoloratious. Occasionally there are unpleasant cicatrices or marks of an intra-uterine lesion. In other cases, and more frequently, the disease first manifests itself tAvo or three Aveeks after birth in the appearance of the syphilitic exanthemata or vesicula. Following this, there is the deterioration of the general health, above named, with squamous, papular, and pustular eruptions, and the associate ulcerations of the throat and mouth. At a still further advanced stage, there is elisease of the nasal cavities, mucous tubercles about the anus, and finally disease of the bones. Dr. Golding Bird described a characteristic snuffling as one of the most marked symptoms of infantile syphilis. AVith this, the " puckered mouth, the position of the very characteristic erup- tion round the lips and anus, in addition to the peculiar and fissured appearance of the surface from Avhich the scales have faded, Avill seldom, if ever, fail to convert a suspicion of the dis- ease into positive certainty." Diagnosis.— AVhile it is sometimes easy to make the diagnosis, the symptoms being characteristic, as above described, at others it is extremely difficult. These may be but the symptoms of bad bh)od and impaired nutrition, as described in the quotation from Hutchinson. Yet whenever one form of cutaneous eruption follows another, after a Avhile associated Avith disease of the throat and nasal cavities, and attended by impairment of the (reneral health, Ave Avill have cause to make strict inquiry whether there is the peculiar discoloratious of the skin or not. Prognosis.—AVhen the symptoms of constitutional syphilis are present at birth, the prognosis is unfavorable; indeed, as a general rule, it is better that such children should die early, for it is almost an impossibility for it to be removed and good health restored. But when it appears some weeks after birth, in the form of syphilida, in a well-developed child, we may expect to effect a permanent cure, if the mother's health is not much impaired. But in most of these cases, the evidence of the syphilitic lesion will still remain as named. The disease makes a permanent im- press on the nutrition of the individual, and may be seen fi.r several generations, though all its active symptoms are arrested. 238 DISEASES of children. Treatment.—The objects of treatment in hereditary syphilis are : to increase the process of retrograde niatamorphosis, and the removal of the broken-down material by Avay of the skin, kidneys, and boAvels ; and to improve digestion, assimilation, blood-making, and nutrition, thus renewing the blood and tissues Avith healthy material. This must be carefully done, for the influence of the syphilitic poison is to depress vitality, and it is much easier to break down tissue than to replace it. The tAvo processes—waste and reneAval —should go on together, the one being the exact complement of the other. Thus, as time passes, the syphilized blood and tissues are replaced Avith new material not contaminated with the poison, and in the course of some months the disease is wholly removed. There is no specific against the syphilitic \7irus; if there Avas its administration Avould suffice. The use of mercury and arsenic temporarily arrests its actiArity in some cases, but they sometimes render it difficult of cure. When the tongue is small and red, I make the folloAving prescription : ly Donovan's Solution of Arsenic gtt. x. to gtt. xx., Tinct, Phytolacca gtt. x., water 5iv., a teaspoonful every four hours. When indicated it sometimes exerts a remarkable influence, clearing the skin, arreeting the ulcerative process, and improving digestion and nutrition. In same cases the mother may be put upon the same remedies in larger doses, as : ly Donovan's Solution 5j-, Tinct. Phytolacca §ij., Avater 5iv., a teaspoonful three or four times a day. Iodide of Potassium is an admirable remedy when the tongue is broad and has a leaden pallor. Sometimes the gums and mucous membranes show the same pallor. For the child I order: ly Iodide of Potassium 5j-> water 5iv , from half to one tea- spoonful every three or four hours. For the mother, if the child is nursing, the proportions of: Py Iodide of Potassium 5ss., water §iv., a teaspoonful three or four times a day. Sometimes much smaller doses may answer for both child and mother. I prefer to treat the young child partly through the mother, if it is nursed. She maybe placed upon the use of the vegetable alteratives—Corydalis, Alnus, Rumex, Stillingia, etc.— using them in Aveak infusion, but quite freely. They can be gotten in pleasant form by the use of some agreeable aromatic, as in the following formula : Py Corydalis §ss., Alnus and Sassafras, aa. 5j , boiling Avater Oiv., put in a covered vessel and keep hot for four hours, then strain and SAveeten to the taste. Any aromatic INFANTILE SYPHILIS. 239 that the patient might prefer can be substituted for the sassafras. In using the vegetable alteratives, I think it best to change them every Aveek, as Ave may in this Avay obtain a stronger in- fluence, and the remedies are less distasteful. AVith this the physician may give acetate of potash to the ex- tent of three drachms, or iodide of potassium to the amount of from one-half to one drachm daily. At the same time the patient, if past the second summer, is put upon the use of iron and the bitter tonics, and has a full diet in which animal fe>od preponderates5. Occasionally we Avill find that the tonic and stomachic is most efficient Avhen com- bined Avith small doses of Podophyllin, as in the folloAving for- mula : Py Podophyllin gr. j., Hydrastia, Quinine, aa. gr. xx., divide in twenty poAvders, and give one three times a dav. The compound tonic mixture,* the formula for which Avill be found in the foot note, is an excellent remedy, and may be em- ployed in this case Avith advantage ; or in place of it, Ave may sometimes use the folloAving: Py Tincture of Muriate of Iron 5ss., Solution of Strychnia 5j-, Glycerine oiijss., a teaspoonful four times a day. The treatment of the child may consist in part of the adminis- tration of the alterative infusions already named. They should be made pleasant, so that the child will take them freely and without disgust. Iron Avith glycerine, as so frequently recommended, Avill prove the best stomachic and restorative. If the chilel is feeble, especi- ally if there is occasional febrile action, I like the inunction of quinine, indeed, I am not certain but Avhat it Avill be found of advantage in most cases. I am partial to the use of alterative baths in infantile syphilis, and have been able to obtain a very decided benefit from them. * Formula for Compound Tonic Mixture.—R Ferri Sulph. 3j.. Soda Phos. 3yj., Quinia Sul. grs. 192, Sul. Acid dil. q. s., Aqua Am- monia q. s., Strychnia grs. vj.. Acid Phosph. dil. f.^xiv., Sacch. Alba §xiv. Dissolve the Iron in 3j of boiling water, and the Phosphate of Soda in ^ij., of boiling water. Alix the solutions and wash the precipi- tated phosphate of iron until the washing is tasteless. AVith q. s. of dil. sul. acid dissolve the quinine in two ounces of water, precipitate the quinine with ammonia, and carefully wash. Dissolve the phosphate of iron and the quinine thus obtained, as also the strychnia, in the dilute phosphoric acid, then add the sugar and dissolve the whole without heat. 240 diseases of children. I generally employ, externally, the same remedies that are used internally. For instance, if Corydalis and Rumex are given, a strong infusion of the same is used as a bath. POISONOUS BITES AND STINGS. Occasionally a physician is called to treat a child Avho has been bitten by a poisonous serpent; but more frequently one who is suffering the effects of the sting of the bee, Avasp, or others of like species. The history of the accident in these cases is usually plain, and their symptoms very marked ; so that there is little danger of mistaking the character of the injury. Symptoms.—The symptoms from the bite of a poisonous ser- pent are manifest in a short time. The patient is prostrated, the countenance pale and listless, body bedeAved with a colel perspi- ration, the pulse small, rapid and fluttering, with droAVsiness and disinclination to speak or ansAver questions. The part bitten usually swells rapidly, anel becomes bluish discolored. In some cases the SAvelling extends to adjeuning parts, and finally the Avhole body is more or less SAVollen anel sometimes eliscolored. All the symptoms are those of prostration, and we may regard the poison as a depressant, having a someAvhat similar actiem to hydrocyanic acid, and at the same time a blood-poison, setting up a process of decomposition. The poison of the sting of the bee, Avasp, hornet, and others of like species, is someAvhat similar in kind, though in much less degree. Usually Ave will finel the disturbance principally local, except the irritation of the nervous system from the extreme pain, which sometimes goes so far as to produce convulsions. The part is much SAvollen, pale at the part stung, but with a red areola, and is exquisitely painful. In some persons, extremely susceptible to the influence of the poison, we will have marked prostration from a single sting. Usually, however, the constitutional symptoms are seen when the person has been stung in many places. In these cases the pulse is small anel feeble, the extremities cold, the face pallid, a sense BITES AND STINGS. 241 of weight and oppression in the praecordia, difficulty of breath- ing, and sense of general prostration. In one case that came to my knoAvleelge the patient Avas unconscious for some hours, and seemingly lifeless for a time. As a general rule, these symptoms pass off in the course of tAventy-four hours. Treatment.—The treatment for the bite of a serpent will be of a stimulant character. Let the Avouud be freely incised, and cupped, or drawn by the mouth, anel afterAvard a strong solution of ammonia applied. Place the patient in bed, covering warmly, and applying dry heat freely. Give internally the aromatic spirit of ammonia with tincture of asafcetida, in full doses, repeateel frequently, with as much strong coffee as the patient can drink. The common treatment in the South-Avest is to give whisky freely, to the extent of k pint or more in a short time, for an adult; but I think it doubtful whether this is as good as the plan proposed. In the case of a sting I haA'e slices of hiav onion applied to the part, and changed frequently. It is very certain and speedy in its action, relieving the pain, and dispersing the SAvelling, usually in the course of half an hour. If there are a number of slings, it should be applied to every one of them, and bound on firmly. In case the general symptoms are developed, I should recom- mend the treatment gi\'en for the bite.of a serpent. If convul- sions ensue, chloroform will probably prove the best remedy. 16 242 DISEASES OF CHILDREN. CHAPTER VI. DISEASES OF THE RESPIRATORY APPARATUS. The respiratory apparatus consists of the cavities of the nose, the pharynx, larynx, trachea, bronchial tubes, parenchyma of the lung, and the investing membrane—the pleura. Each of these parts may be the seat of diseased action separately, or tAvo or more may be engaged at one time. The diseases are mostly of an inflammatory character, but in addition we have them de- pendent upon morbid innervation, and change of structure de- pendent upon causes other than inflammatory. We diagnose these diseases in part by the general symptoms, as Ave do affections of other parts of the body. But to confirm such diagnosis and render it more exact, Ave are guided by cer- tain physical signs, manifest to the senses of sight, hearing, and touch. This is called physical diagnosis, to distinguish it from the ordinary means by general symptoms. AVe purpose giving but a brief space to the subject of physical diagnosis here, merely pointing out the differences betAveen the child and the adult. For further information the reader is re- ferred to special monographs on the subject, or to treatises on the practice of medicine. The information for physical diagnosis is obtained from an examination of the conformation of the thorax, respiration, cough, sputa, and from auscultation and percussion. Conformation of the Thorax.—But little information is obtained from the form of the thorax in acute disease. In some cases of chronic disease, the narrow and flattened chest, Avith feeble respiratory poAver, Avill be additional evidence of feeble viablility. But it is of more importance if it impresses upon us the necessity of passive and active exercise of the thoracic mus- cles, and increased inspiratory effort to obtain a better develop- ment. There is no doubt but that the movement cure may be applied in this case with great advantage. Respiration.—The respiratory movements of the child are more open and free than in the adult, and at the same time more superficial. Changes in the respiratory movements have less diseases of respiratory organs. 243 diagnostic value than in the adult, because they may be influ- enced by slight lesions, or by derangements of the nervous sys- tem. Considerable irregularity of the respiratory movement is permitted, Avithout seriously interfering Avith the function. Respiration normally is both thoracic and abdominal; if it is changed in this respect, it is evidence of disease. Thoracic res- piration is caused by acute inflammation of the liver, stomach, or spleen, or from peritonitis; but the most frequent cause is from an irritable state of the boAvels, sometimes met with in severe cases of ceilic. It is abdominal in pleurisy, pericarditis, and in extreme debility. Respiration is increased in frequency from tAvo causes : First, in consequence of an increased frequency of the circulation, to Avhich it bears the normal relation of one to four; and second, from p'isease of the respiratory apparatus, the capacity of the lungs being lessened, the respiratory movement is proportionally frequent. A sIoav and free respiration indicates an easy circulation of the blood, sound lungs, and an unimpaired distension of them. If the respiration is large and attended Avith difficulty, much exer- tion being necessary, it indicates loss of nervous poAver and approaching coma or stupor. The short respiration, when un- attended with pain, is a very certain symptom of obstruction of the lungs. Difficult respiration is manifested by labored breathing, the inclination being to assume a sitting position, and in the child by the clutching movements of the arms and hands. There are also the additional evidences from imperfect aeration of the blood. Cough.—Cough is an indication of irritation of the respira- tory mucous membranes, and may be produced from disease of any part. The purpose fulfilled by the normal act of coughing is the removal of irritating matters Avhich may be in the air- passages. The irritation of disease gives the sensation of some- thing irritant within the bronchial tubes, hence the cough. The act of coughing removes increased secretion of mucous, and keeps the air-passages free for the performance of the respiratory function. Cough may be sympathetic—depending upon disease of some part other than the lungs, as when it arises from disease of the 244 diseases of children. stomach, liver, or other abdominal viscera. Or it may be de- pendent upon the irritation of the nervous centers, especially of the base of the brain, as Ave have a marked example in whoop- ing-cough. The short irritative cough is generally met Avith in the first stages of inflammation of the parenchyma of the lungs. The hoarse and stridulous cough results from laryngeal disease. The holloAV, rattling cough is found in bronchitis, with increased se- cretion. A dry cough indicates Avant of secretion; a moist or mucous cough, increased secretion. Sputa.—While Ave obtain considerable information in diseases of the adult from an examination of the sputa, Ave learn but little in diseases of childhood. The adult raises the secretion by an act of coughing, and spits it out; the child raises it^to the larynx, and SAAralloAvs it. If the sputa is ejected, and can be examined, it will give the same information as in the adult. Percussion.—The practice of percussion does not give the same information as in the adult. The walls of the chest are not so elastic, and the comparative resonance or dullness is affected by minor circumstances in a greater degree. Neither do Ave have solidification of the lungs even in pneumonia, as in the adult Still, resonance on percussion gives the information that the lungs are permeable for air, and there is no structural reason for impaired respiration. And dullness on percussion is evidence of congestion, or of effusion into the structure of the lungs. Auscultation.—AVe obtain the most certain information in regard to the condition of the respiratory organs from ausculta- tion ; yet should Ave be guided by the statements of writers on auscultation, Ave would be led inte) frequent errors. We have no sibilant, sonorous, dry crackling, crepitant, subcrepitant, mucous, or cavernous rhonchi in children, and those avIio auscultate with the expectation e>f hearing such sounds will be mistaken. The sounds heard may be divided into tAvo classes, dry and moist blowing sounds; they are all blowing sounds, and I use the Avord in its literal signification. They are dry in various degrees, and they are moist in various degrees, Avhich the ear soon learns to appreciate. Dryness indicates an arrest of secretion, and CORYZA. 245 contraction of the bronchial tubes ; as is the dryness, so is this condition. Moist blowing sounds indicate the establishment of secretion, and in proportion to the moisture, or rattling, is the abundance of the secretion. The sounds also give evidence of the condition of the bronchial tubes, as regards tone. If the sound is Avell defined or acute, the tubes are contracted, and in proportion as the sound is Avaver- ing and IioIIoav, they are relaxed. Getting the timbre of the sound is the most important part of the education of the ear. The respiratory murmur is very distinctly heard in the child, being once or tAvice as loud as in the adult, se> that beginners in auscultation are recommended to commence the training of the ear, and to get a better knoAvledge of this natural sound, by auscultation of the child. AVhen this sound is present Ave know the parenchyma of the lung is not involved. It is changed in inflammation of the lungs, becoming coarser and less even, and broken by mucous cracklings. It is masked by the moist blov- ing sounds of bronchitis, and these sometimes mask the change in its character—in the latter stages of an inflammation of the lungs. CORYZA. A mild form of coryza is of very common occurrence in the chilel, and Avhile it is mild and demands but little treatment, it is a source of great annoyance to the child, and from the restless- ness that attends it, to the family. The severe form of the disease is a true inflammation of the nasal cavities, and causes considerable constitutional disturbance in addition lo the local uneasiness. Symptoms.—In the first form, the nose becomes stopped by accumulations of mucus, and the child draws its breath through the nose with difficulty, and finally is compelled to breathe wholly through the mouth. The adult finds such a state of things sufficiently annoying, but the child can see no reason fe>r it, and no cause avIiv it shall have patience under the infliction, and consequently makes known its objections in violent crying. The nose may remain stopped in this way for several hours, and it may be repeated day after day for a week or more. Usually it is associated with slight cold, and Avhen this passes aAvay the trouble ceases. 246 diseases of children. In the second form there is a similar condition of the nose, and the same restlessness and suffering in consequence In addition to this the child manifests symptoms of febrile action and arrest of secretion ; the face is flushed, the eyes injected, and the head is hot, The closing of the nose in this case, during the first tAvo or three days, is dependent upon SAvelling of the nasal mucous membrane. After this there is free secretion and discharge, but when this is retained it closes the passages. AVith the subsidence of the fever and the establishment of secretion, the disease passes away. Treatment.—In the first and simple form, thoroughly rubbing the nose and over the frontal sinus with hot lard, or any fatty matter, will give present relief. If the child is suffering from cold, the use of an infusion of Asclepias Avill generally be all that is required. In the second form of the disease the patient is put upon the use of the sedative, Aconite or Veratrum, in the usual doses, anel the action is aided by the hot foot-bath. In some cases the dis- charge is acrid, and though the child may not complain of burn- ing, Ave can see by the expression of its face that there is much irritation of the mucous membrane : Ave use Rhus with the Aco- nite. If the child is dull, and wants to sleep a great deal, Bel- ladonna is used. If the head is hot, and the face flushed, the remedy is Gelseminum If the tongue is pale, the thnuit sore, or any enlargement of the lymphatic glands, give Phytolacca. Some cases will present themselves in which marked benefit will be derived from sulphite of soda or sulphurous acid. The first, if the tongue is pallid and dirty, or if there is eczema; the sec- ond Avhen the tongue is reel and dirty, and the tissues somewhat puffy. The use of inhalations of the vapor eif Avater and vinegar give great relief, and may be emphwed several times a day in bad cases. In place of this Ave may use a friction to the nose of tinc- ture of Aconite gtt. x. to gtt. xx., lard 5j.; mix. CHRONIC CATARRH. Chronic catarrh is not of as frequent occurrence in childhood as in the adult, yet we meet Avith cases from the age of three years upwards. In some cases it seems to be dependent upon an chronic catarrh. 247 enlargement of the mucous follicles, thickening of the mucous membrane, and increased circulation. In this case the discharge from the nose is of mucus only. In other cases there is a true chronic inflammation, producing thickening of the mucous mem- brane and superficial ulceration, and the discharge is muco- purulent. Symptoms.—In the first case there is too free secretion from the nose, the constant discharge becoming disagreeable. In aeldi- tion to this the voice is changed, and has a nasal tone, Avhich is sometimes disagreeable. In some cases the nasal cavities become closed at times/from accumulation of the secretion, and this is very unpleasant to the patient. In the second case there is the free discharge from the nose, but uoav it is frequently fetid, anel is otherAvise unpleasant. The patient complains of pain over the nasal bones, and frequently a frontal headache, which may be le>cated in the frontal anel orbital sinuses. In adelition to this, there is the unpleasant nasal tone to the A'oice, anel the occasional stopping up of the nose, com- pelling the child to breathe through the mouth. In some cases the disease is confined principally to the superior portion of the cavity, extending backAAiird to the posterior nares. In others the posterior nares and the upper part of the pharynx back of the soft palate, are principally involved. This gives rise to a peculiar IioIIoav voice, and occasionally to some difficulty in articulation, and an unpleasant gurgling noise in SAvallowing. In both of these cases the secretion pours backward, and drop- ping into the pharynx, is ejected by an act of haAvking and ex- pectoration. The general health suffers more or less as the disease continues, especially in the second form. The appetite is impaired, diges- tion deranged, and poor blood is formed, and from this Ave have imperfect nutrition. I do not think such cases are necessarily scrofulous, but as the disease progresses, a condition very similar to scrofula is developed. Diagnosis.—The diagnosis is not difficult, as the continued abundant discharge from the nose, its occasional closure, the nasal tone of voice, and the pain and uneasy sensations in the nose and frontal region, are very prominent. 248 diseases of children. Prognosis.—The disease Avill rarely if ever get well without treatment; but au appropriate general and local treatment, if continued sufficiently long, will effect a radical cure. Treatment.—In many cases a general treatment is necessary to success; in some cases, however, nothing but local means Avill be indicated. The general treatment wi 11 vary according to the indications, and much care Avill be necessary to select the right remedy. The possible remedies might be named, as Arsenic, Iron, Lime, Sulphite of Soda, Sulphurous Acid, Hamamelis, Alnus, Scrophularia, Phytolacca, Donovan's Solution, Iodide of Potassium. The relaxed, atonic skin, with feeble circulation, will be benefited by arsenic; pallid skin, Avith blue veins, iron ; dusky redness of mucous membranes of nose and throat, Avith occasional erysipelatous flushings of skin, tincture of muriate e>f iron. Lime is used when there is acid dyspepsia, or a tendency to inflammation of cellular tissue—lime-water or hypophosphite of lime; sulphite of soda, if there is eczema of the face; sul- phurous acid, if there is deep redness of mucous membranes, with offensive discharge; Hamamelis, if the tissues are full and atonic; Alnus and Scrophularia, if there is purulent secretion, Avith the formation of unpleasant crusts or scabs; Phytolacca, if the throat is sore, or the cervical glands enlarged; Donovan's solution, if the bones are being involved, the skin dirty, and especially if a syphilitic taint is suspected ; iodide of potassium, if there is a broad atonic tongue, Avith leaden pallor. In some cases I have employed Rhus with Aconite or Vera- trum, with most marked benefit. The Rhus has the usual indi- cations, frontal headache, persistent, with burning in the eyes or nose. The Aconite is suggested by the irritable tonsils and throat, and the Veratrum by cough and mucous rattling in bronchia. At the same time the child should have its regular bath every one or tAvo days, using the alkalies when indicated, the tonic bath if the child is anaemic, or the fatty inunction if the skin is dry and harsh. AVith young children it is someAvhat difficult to make proper use of local remedies. AVith such I prefer to use them by inha- lation, or Avith the steam or air atomizer. In this Avay they can be brought into direct contact Avith the diseased structures. AVhen the child is old enough (six years) to use it, the nasal chronic catarrh. 249 douche may be employed (Thudieum's method), the fluid being passeel into one nostril and flowing through the nasal cavity anel out at the other. The Thudicum apparatus consists of a glass vessel, holding a pint or quart, to the bottom of which is attached a piece of rub- ber tubing six e)r eight feet long, furnished with a stop-cock to turn on or off the fluid, and a nose-piece to fit in one nostril. The method of using it is as follenvs : Place the vessel containing the fluid on a shelf or stand three or femr feet higher than the patient's head, and place the ne>se piece in one nostril; now let the patient open his mouth, breathing through it entirely, turn on the fluid, and it Avill pass through the nose, and out of the other nostril, as described. A vessel may be placed before the patient to receive it. If such apparatus is not at hand, one may be improvised by taking an ordinary bottle to contain the fluid, anel a piece of half- inch rubber tubing six or eight feet long to conduct it to the nose. Place one end of the tube in the bottle so that it may reach to the bottom, apply the mouth to the other end, and by suction draw the fluid through, then compressing it with thy fingers, introduce it into the nostril, and proceed as before. It is the ordinary syphon, anel Avill continue to discharge until all the fluid in the vessel is removed ; its force will depend on the elevation of the vessel. Another method is to use the ordinary rubber-pump syringe, the fluid passing into one side, going through the nasal cavities and out at the other nostril, so long as the patient breathes through the mouth. AVith either of these, so soon as the patient shuts the mouth the fluid will pass down the throat, or into the larynx if the patient makes an inspiration. Of course the sense of strangulation stops its use until the pa- tient gets breath and starts fairly again. The remedies used by the atomizer will differ somewhat from those used by the hydrostatic method. I have obtained good results from the use of a solution of chlorate of potash (gr. x. to water 5'iv.), alternated with Pond's extract of Hamamelis; or in place of the preparation of Hamamelis named, we may use one part of the tincture to three of water. AVhen the discharge is purulent and offensive we may use the solution of permanganate of potash grs. x. to water 5iv to Sviij., depending upon the con- dition of the mucous membrane. In place of this, a solution erf carbolic aciel, one part to twenty, may be used with good results. 250 DISEASES OF CHILDREN. Within the pasttAvo or three years I have used a solution of Salicylic Acid Avith Borax or Avith chlorate e>f potash with excel- lent effect. The strength Avould be, ly Salicylic Acid gr. x., Borax or Chlorate of Potash gr. x., water 5iv. The apparatus for atomizing is now so goe)d and so cheap, (the Essex selling for $1.50 and $2.00, the Adams for $2.00,) and the method is so easily employed even with young children, that I give it the preference. It Avill not do to forget the old means in looking after the new, anel there are cases in Avhich a filtered infusion of equal parts of Alnus, Rumex, anel Quercus Rubra, Avill be preferable to any other remedy. These are cases of profuse secretion of muco-pus, with probable disease of bone, and marked development of the nasal A'oicc. AVith the hydrostatic apparatus, Ave use a solution of common salt oss. to the pint of Avater, to cleanse the nose and remove the mucus or muco-pus. Not unfrequently considerable quantities of offensive material, with large unpleasant looking crusts, Avill be brought away. FedloAving this, use a solution of chlorate of potash, varying in strength from gr. x. to 5j-> to the pint of water. In a large number of cases Ave find that these simple means are sufficient for a cure. Occasionally it may be Avell to alternate Avith this an infusion of Hydrastis or Hamamelis, or the distilleel extract of Hamamelis diluted Avith one part of Avater. If the discharge is very offensive, Ave employ the solution of salicylic acid and chlorate of potash ; or instead of this, a Aveak solution of carbolic acid may be used. To relieve the pain and unpleasant sensations in-the frontal region, I ahvays direct the local application of tincture of Aconite root over the part. It is applied with the finger, and of course is used in small quantity. The use of the voltaic battery, the current being passed from the nape of the neck through to the part in front Avhere the pain points or reversed, relieves the unpleasant sensation, and it is claimed aids in the cure. CHRONIC PHARYNGITIS. Chronic disease of the pharynx, fauces, sefft palate, and tonsils is occasionally met Avith in the child, and is generally of an in- flammatory character. All of these parts may be involved in the disease at once, or one or tAvo may be affected separately. It CHRONIC PHARYNGITIS. 251 is frequently associated Avith disease of the posterior nares, and occsionally with disease of the larynx and bronchia. Causes.—Occurring in persons of feeble vital power, and consequently poor blood and impaired nutrition, we can easily see Iioav any irritation may progress anel run into this disease. AVith such conditions of the system it is most frequently caused by colel, and folloAvs orelinary sore throat. Repeated attacks of tonsillitis, or of sore throat, may give rise to it in persons other- wise of good constitution. It may also be a sequel of diphtheria which has prevailed so extens'iA'ely during the past ten years. Pathology.—The mucous membrane covering these parts is thickened, the blood-vessels, especially the veins, enlarged, anel the mucous follicles increased in size and activity. AVith this changed and enfeebled condition the transformation of epithelial cells into pus cells, and the reparative material into pus, is easy ; and at a further advanced stage erosion, superficial ulceration, and at last deep ulceration, Avould naturally folloAV this condition of the tissues. Symptoms.—It is noticed that the child is easily affected by cold, frequently complaining of sore throat; that it frequently clears the throat by an act of haAvking, and expectorates a mucus or muco-purulent material in considerable quantity. There is also a change in the voice, readily recognized by one who has not become accustomed to it like the family. Quite often the child Avill make an unnatural gurgling noise when it sleeps, or it may be, it Avill snore like an adult. The constitutional lesions vary in different cases, in some marked, and in others slight, but as they are only incidentally related to the disease Ave are describing, it is not necessary to enter into a detailed description. Diagnosis.—The symptoms above named having.drawn our attention to the throat as the seat of a elisease, Ave make an ex- amination of it, by placing the patient in a good light and de- pressing the tongue. I prefer the use of a hand-mirror to reflect the light, concentrating it in the throat. In using this the patient is placed with his back to the window, in such position that Ave can catch the direct rays of the sun upon the mirror, and throw them in the throat. Or, using a lamp, which is more 252 diseases of children. convenient, it is placed by the side of the patient on a level with the head, when the light may be readily thrown into the pharynx with the mirror. Making such examination we find the mucous membrane thickened5, relaxed, changed in color, and the tonsils enlarged and spongy, and covered by the mucus or muco-purulent secretion. Treatment.—The general treatment named for chronic catarrh will be applicable to this case. If called in consequence of a recent cold, (which ahvays increases the throat trouble,) Ave will administer Aconite with Phytolacca or Avith Rhus as may be indicated. If the mucous tissues are deep-reel and relaxed, sulphurous acid can be given Avith advantage, especially if the tongue is dirty and the breath bad. With the dull purplish color of mucous membrane, and sometimes also of face, the patient should have Baptisia. Restoratives are very generally indicated, and Ave select them as heretofore named. Minute doses of Veratrum and Arsenic, Compound Syrup of the Hypophosphites, Cod-liver Oil, the diffent preparations of malt, Hypophosphate of Lime, inunctions with Quinine, etc. If the child is old enough to use a gargle we may employ the Hamamelis, alternated Avith chlorate of potash. The Hamamelis may be used in the form of the tincture, gss. to water giv., the chlorate of potash in solution, 5j- to water Oj. In place of the Hamamelis Ave may use the Hydrastis, Cornus, Alnus, or Marsh Rosemary. If the chilel can not use a gargle, the same remedies may be employed with the spray apparatus. Occasionally good results may be obtained by using a remedy in poAvder, allowing it to dissolve on the tongue, SAvalloAving sloAvly. In this Avay Ave may emph)y the folloAving: ly Chlorate of Potash 5j-, (or Alum gr. xx.,) Tannic Acid gr. v., Gum Arabic poAvdered, AATiite Sugar, aa. 5ij.; triturate thoroughly and divide into poAvders of five grains. In place of this Ave might use a pastile or lozenge in the fe>rm of Dr. Anton's, which has proven quite available. The formula is given in the foot-note* * ft Cubebs, fresh and finely pulverized, two ounces; Chlorate Potash half ounce; Gum Tragacanth one and a quarter ounces; Refined Sugar tonsillitis. 253 A flannel cloth wrung out of cold vinegar and applied around the throat, with a dry flannel over it, on going to bed, is a very important aid to the treatment. If the vinegar produces irrita- tion of the skin it should be diluted. AVhen the cloth is removed in the morning, the neck and shoulders should be washed in cold water, using it freely, but drying with brisk friction. This is the most certain means to prevent the frequent taking cold, which in some cases seems to be the greatest obstacle to perma- nent recovery. TONSILLITIS. Inflammation of the tonsils is a very peculiar disease, in that the tendency to it is hereditary in some families, and that, hav- ing once occurred, there is a continued predisposition to it, and it continues to recur, sometimes during the entire life-time. It is also peculiar, in that an inflammation so active in form should be confined to a small gland, and not extend to adjacent structures. Causes.—Tonsillitis occurs most frequently at the commence- ment or breaking up of Avinter, Avhen the weather is very change- able. A slight cold, contracted at such times, will be folloAved by an attack. Pathology.—The tonsils are composed of an association of follicles, terminating on the free surface by twelve or fifteen ducts, through Avhich the secretion is passed for the lubrication of the fauces. These follicles are bound together with a rather loose areolar tissue, and the whole is iiwested by a reticulated fibrous capsule, anel coA'ered externally by mucous membrane. fourteen ounces; Tincture Collinsonia Canadensis three fluid ounces; Tincture Stillingia half fluid ounce; Tincture Capsicum thirty drops; Essence of Peppermint thirty drops. Add the tinctures to a few drachms of the sugar and evaporate, then mix all the ingredients and triturate thoroughly; add of boiling water two and a half ounces; mix and work well in the mortar, and set aside (bottom upward to prevent evaporation) for twenty-four hours, to allow the water to soften and incorporate with the gum and sugar. Cut out slices, flatten out with a roller on a pill tile to a uniform thickness, using sugar of milk or starch powder to prevent the mass from adhering to the tile and the roller, and the lozenges to each other. Cut out the lozensros with a flaring tin punch, a full half inch in diameter, so the lozenge will wei-rli eight grains. Let them dry until hard before using. Avoirdupeia weight is used. 254 DISEASES of children. The structure is such as to permit very great variations in size. Thus, in simple congestion, they may attain a size three or four times as large as in the normal state, and under inflammatory action Avith exudation, their bulk is still further increased. The looseness of the tissue likeAvise permits organized exudative material to once or tAvice the usual size of the organ, without materially interfering Avith their function, as Ave see in protracted cases of tonsillitis. Symptoms.—Quinsy usually manifests itself first, by soreness and stiffness of the throat, with difficult deglutition, and more or less derangement of the digestive functions; occasionally it is ushered in with a marked chill, folloAved by febrile reaction. There is always some fever, dryness and constriction of the skin, and general arrest of secretion. In a feAV hours the patient com- plains of pain, anel a sensation as if some foreign body were present in the throat, with heat and constant desire to swalloAV. AVhen fully deATeloped, deglutition becomes so difficult and painful as to occasion extreme suffering, and in some cases it is impossi- ble. A guttural cough with frequent desire to remove the secre- tion from the throat; a hoarse and difficult respiration, and confused Avhispering and guttural articulation, or sometimes entire loss of voice, is observed. In the severer cases it becomes impossible for the patient to lie down, and in many, but little rest is obtained in consequence of the difficult respiration when the will is in abeyance. If Ave examine the throat in this disease, we will find the tonsils enlarged and reddened; some- times so large as to entirely close the opening of the fauces. An attack of quinsy continues for a variable length of time; usually from four to twenty days, and terminates sometimes by resolution, at others by suppuration. AVhen it terminates the latter Avay, the gland rapidly enlarges ; there is a dull throbbing pain or aching, and a yclloAvish color near Avhere the pus points; usually it readily comes to the surface and discharges Avithout assistance, but sometimes it is \Tery sIoav and requires the bistoury. A condition of chronic inflammation and enlargement fre- quently continues, in those predisposed to the disease. The glamls appear prominent on examination ; the mucous follie-les enlarged; the color a dusky-red, and considerable tenderness. Associated Avith this, Ave frequently have a chronic irritation Avith determination of blood to the entire isthmus of the fauces, and tonsillitis. 255 elongation of the uvula, giving rise to a continuous disagreeable cough, derangement of the general health, finally inducing seri- ous disease of the respiratory apparatus Diagnosis.—The diagnosis is very readily effected, as the symptoms pointing to disease of the throat are so prominent as to lead to its examination at once. Upon depressing the tomrue one or both tonsils will be seen enlarged and reddened. Day bv day we find the SAA-elling increasing, until, if both tonsils are engaged in the disease, they will have quite closed up the isthmus of the fauces. The deep, throbbing pain in the part, greater difficulty of respiration and deglutition, Avith yellowish discolora- tion, give information of the establishment of suppuration.* Prognosis.—Though these symptoms are sometimes very urgent, and the patient suffers extremely from a sense of im- pending suffocation, not one in a thousand will die of the disease. Yet it has been one peculiarly difficult to influence Avith reme- dies; and the radical cure of the disease, Avhere there has been a predisposition to it, has been considered impossible, except by total ablation. Treatment.—The use of Aconite Avith the spray instrument is almost specific in the early stage of the disease. I have em- ployed the steam atomizer, but the Bergsen tubes operated Avith the rubber bellows, the Richardson apparatus in its many mollified forms, Avill ansAver the purpose, or the small Essex spray is very good. AVith the steam atomizer I use it in the proportion of gtt. xx. to Avater §ij., Avith the air spray gtt. x., to water f>iv. The spray is used as often as every four hours, for five minutes at a time, until relief is obtained. In many cases I have suc- ceeded in arresting the disease Avith the one application. It is well to have the patient spit out the Aconite that accumulates in the mouth, as there will be too much to SAvallow. AVhen these instruments are not at hand, let the patient inhale the vapor of vinegar and Avater, and apply to the thre>at the Linamentura Stillingia on flannel. The internal remedy in this case Avill be Aconite alone, using it in the usual proportion, anel repeating it cverv hour. There is no doubt about the specific action of the remedy, even when taken in these small doses, though it is not so certain as Avhen used with the spray. Some- times Phytolacca, Belladonna or Rhus may be added to the sed- 256 DISEASES of children. ative. If the tongue is red and dirty, and the tissues of the throat red and relaxed, sulphurous acid is a very gooel remedy. Penciling the tonsils with the strong tincture of Veratrum Avill also exercise a marked influence on the inflammation, and will sometimes arrest it at once. These means shoulel be persisted in, and if they do not arrest the inflammation they Avill most frequently prevent suppura- tion. AVhen they prove ineffectual, I am satisfied that there are no means Avhich Avemkl have given better results, ami Ave wait the result of suppurative action with patience. Much relief is iioav given by the use of inhalations, and sometimes by hot fomentations applied to the throat. As a general rule the abscess will open itself, and this Ave would ahvays prefer in children. If it does not, and the symptoms of obstruction in the throat be- come alarming, Ave Avill have to lance the tonsils. This is not very easily done, but by guarding the bistoury with the finger, it may be accomplished Avithout danger. The treatment for the radical cure of the disease Avill vary in different cases. If the tonsils alone are affected, the general health being good, I think Ave may hope for a cure in the child. For this I rely principally upon the local application of persul- phate of iron ; at first one part to three of glycerine, but increas- ing its strength as the treatment progresses, until it is used of full strength if necessary. T.ie continued use of the tincture of Hamamelis, applied to the tonsils once or tAvice daily, Avill also give good results. If there is disease of aeljacent parts, the treatment advised in chronic pharyngitis will be used in addition. When these means fail, Ave will have to take into consideration the propriety of excision. It is claimed by some, that the remo- val of the tonsils leads to tuberculosis of the lungs, and this claim is based upon considerable experience in sections of coun- try where tonsillitis prevails. AVhy such a result should folloAV I can not see. The tonsils are removed Avith a tonsillitome, or guillotine, and is easily effected, and Avithout risk. The important part of the operation is to include the Avhole of tonsil in the ring of the instrument, so as to remove it Avhen the knife is throAvn fonvard. If not Avholly removede, the disease may be reproduced, just as if nothing had been done. If there should be hemorrhage fol- lowing the operation, pencil the part Avith persulphate of iron, or a saturated solution of alum. CROUP. 257 CROUP. Croup is laryngitis of the child, and yet it differs very mate- rially from that disease in the adult. This difference is owing in part to the imperfect development of the larynx in the child, as compared■ with the adult, and to a limited extent, the differ- ence in the pre)gress anel results of the inflammatory action. Thus it is well to retain the name of croup for the laryngeal affection of the child, to prevent confounding the disease with the laryngitis of the adult. AVe recognize three femns of croup, mucous, pseudo-membra- nous, and spasmodic. Though alike in some of their features and symptoms, it is well to stuely them separately. MUCOUS CROUP. This is the most common form of the disease in our Avestcrn country, comprising, probably, two-thirds of all the. cases met Avith. It varies in intensity in different localities, at different seasons, and in different persons. Thus in some places it is a very common elisease, in the late autumn anel early winter, anel in the spring, Avhen Avinter is breaking up; as on the shores of Lake Erie. While in some othe-r sections croup is rarely seen, as in Cincinnati aAvay from the river. Causes.—The cause of this, as Avell as other forms of croup is ce>lel, Avith its arrested secretion anel derangement of the circula- tion. AVhy it should particularly affect the small surface of mucous membranes lining the larynx, Ave are unable to say, as Ave are unable to account for many things Ave meet with in the study of medicine. Pathology.—This is a true inflammation of the mucous membrane of the larynx, though not of an active character. It is sufficient, hoAvever, to cause an increaseel circulation of blooel to it, some impairment of the capillary circulation, and an in- creased activity of the mucous follicles. It might properly be termed follicular laryngitis There is but little thickening eff the mucous membrane ; in- deed, all there is depends upon the increased distension of the blood-vessels. We have, therefore, to looksomeAvhereel.se for i7 258 DISEASES of children. the cause of the difficult breathing, Avhich is so prominent a symptom. This is partly owing to accumulations of mucus in the larynx, but principally to contraction of the intrinsic muscles of the organ, from the irritation of the mucous membrane. Thus post-mortem examination does not sIioav the larynx occluded by structural change, as many Avould suppose. In some cases, it is true, there are considerable accumulations of mucus, but in most the larynx is sufficiently free for respiration, and Ave must conclude that the child has been asphyxiated by the spastic contraction of the laryngeal muscles. Symptoms.—Frequently for a day or two before the attack the child will have had symptoms of cold, with a slight cough. Both the cough and voice are frequently a little hoarse and rough, and would be recognized by a person acquainted Avith the dis- ease as croupal. The attack of croup occurs most frequently at night, though it may be in the day time. The child seems to be suffering more Avith its cold during the evening, but still it is not sick, and it is put to bed Avithout, probably, a thought of danger. But along about the middle of the night the parents are aroused by the child starting out of sleep with difficult respiration, a hoarse voice, and a croupal cough. The respiration is rough and whistling, the cry hoarse and feeble, except when a great effort is made, when it becomes shrill and piping. At first the difficulty of respiration is intermittent, but after an hour or tAvo it becomes permanent, and there is a peculiar whistling or gurgling sound as the air passes into and out of the larynx. As the disease progresses the difficulty of respiration becomes more marked, and the cough is hoarser, has a peculiar metallic tone, and the voice sinks to a Avhisper. If the child sleeps mucus accumulates in the throat, the breathing becomes more and more difficult, until at last the child Avakes with symptoms of asphyxia. At first the skin is dry, its temperature increased and the pulse full and hard. But as the respiration becomes more difficult, a cold clammy perspiration breaks out, the extremities become cold, and the pulse frequent and feeble. The disease runs its course in from tAvelve to twenty-four hours, terminating in a subsidence of the disease or death. CROUP. 259 Diagnosis.—The hoarse metallic (croupal) cough, Avith hoarse- ness and change of voice is sufficient evidence of croup, but it does not inform us Avhich of the three varieties it is. In mucous croup, there is the slight febrile action to distinguish it from the spasmodic variety, and the evident presence of mucus in the larynx manifested by the rattling sound heard on auscultation, and Avhen the patient coughs, which distinguishes it from the pseudo-membranous form. The evidence of increased secretion of mucus in the throat is the diagnostic feature of this disease, though other points of distinction Avill be named when Ave describe the tAvo other forms. Prognosis—Though some cases of mucous croup are very severe, and require careful and close attention, yet we may regard the prognosis as favorable. I do not think the mortality should exceed from tAvo to five per cent. Treatment.—Three methods of treatment may be pursued, and either of them Avill give success if properly carried out; or, if the practitioner chooses, he may take a part of each and form his oavii treatment out of it. I may premise by saying that the treatment generally adopted, of giving emetics for the purpose of emesis, is the Avorst that could possibly be done, if Ave except .the insane idea of the local application of nitrate of silver, by the followers of Dr. Green. It makes very little difference what emetic agents are employed, if the object is speedy vomiting; for such action is not attended with relaxation or sedation in one-half the cases, Avhile the efforts at vomiting throw the larynx into action, cause increased determination of blood, and increased irritation of the intrinsic muscles. There is no more certain way to destroy the life of the child than this. Emetic agents, liOAvever, may be used in the treatment of croup with success, and Ave will consider this use, as the first plan. The objects we Avish to accomplish are: first, relaxation of the larynx te> give better respiration ; second, to produce sedation, and thus lessen inflammatory action; third, to increase secretion and thereby get a material less tenacious and more easily removed, and at the same time deplete the engorged vessels of the part. Fe>r this purpose they should be used in small doses frequently repeated, so as to produce nausea and its effects—relaxation and 260 DISEASES of children. sedation—Avithout emesis. I prefer preparations of Lobelia, but other nauseant emetics may be used with gooel results. The acetous emetic tincture of our Dispensatory will be found to ful- fill all the indications. Aconite alone is the principal internal remedy in the secemd plan of treatment. I have no doubt of its specific action in this case, even in small doses. I would prescribe it in the propor- tion of: Py Tincture of Aconite gtts. j. to iij., water 5iv., a teaspoonful every fifteen minutes. Veratrum may be used in some cases in the proportion of gtt. v. to gtt. x., to water §iv., and alternated Avith the Aconite. The external remedy in this case, as well as in the others, is the application of the Stillingia liniment to the throat over the larynx. It may be applied with the finger or a piece of soft flannel or cotton, and the application repeated every half-hour or hour. In some cases this remedy locally applied is all-suffi- cient for a cure, and relief Avill be noticed within an hour. Occasionally we administer it internally in doses of half a drop to one drop on sugar; it may be repeated every half-hour or hour. In families Avhere croup is of frequent occurence, it is Avell that the mother should have a bottle of Stillingia liniment, and be instructed to use it on the first appearance of hoarseness. The formula for this preparation Avill be found in the first part. I greatly prefer the second plan of treatment. AVhen the breathing is very difficult, hot Avater may be applied to the throat with flannel cloths assiduously, until relief is obtained. This part of the treatment is of much importance, and requires that the application of heat be constant, and that the surface is not alloAved to be chilled by exposure as the cloths are changed, or by Avetting the clothing. The third plan of treatment is by the use of inhalations, the vapor of Avater or vinegar being the basis, and medicated as the case seems to demand. The steam spray apparatus is an ex- cellent instrument for using inhalations in this case, though if it is not at hand Ave may improvise our means from a tin vessel containing the fluid, anel a hot iron to raise the vapor. AVith the spray apparatus I use the preparation of Aconite, named above for internal use, or equal parts of vinegar and Avater in the cup, or if the sounds are whistling, lime water. The ordi- nary inhalation will be of vinegar and Avater, or of au infusion of hops or tansy. croup. 261 AVith either of these means the hot application to the throat is important. Or, Avhen it can not be conveniently employed, or Ave are afraid to trust the nurse, Ave avill apply the compound Stillingia liniment, or in place of this, a cloth sufficiently large te> cover the throat and upper part of the chest is spread with lard and freely sprinkled with the compound poAvder of Lobelia and Capsicum, and applied. The old-fashioned snuff plaster, made in the same Avay, answered a good purpose. PSEUDOMEMBRANOUS CROUP. This form of croup is fortunately of rare occurrence, as it is much more severe than the others, and, if not treated promptly and skillfully, will terminate fatally. Causes.—This variety is produced by the same cause, colel, as the other forms, though there is some difference in the general health of the patient, Avhich, in one case, gives increased secre- tion of mucus, and in the other a plastic exudation. Pathology.—This is a true inflammation of the larynx, com- ing on gradually anel progressing slowly in the majority of cases, and attended with plastic exudation upon the mucous membrane. In this case Ave find the mucous membrane no more thickened than could be accounted for by its injection with blood ; and even Avhere loosely attached there is no submucous infiltration. Post-mortem examination sIioavs the femnation of a false mem- brane from the one-tAvelfth to the one-sixth of an inch in thick- ness. This of a grayish-Avhite or yelloAvish-Avhite color, opaque, anel of considerable tenacity. Microscopic examination sIioavs it to be composeel of mucus, epithelial cells, and an obscure fibrous structure, the result of organization of the plastic exudation. It varies greatly in its tenacity of adhesion to the mucous mem- brane; in some cases it seems almost to form a part of it, and is detached Avith great difficulty ; in others it is very loosely attached, and may be loosened and removed by simple pressure on the larynx externally. In a large majority of cases this false membrane is not e>f sufficient thickness to account for the arrest of the respi- ratory function, and Ave must regarel the spastic contraction of the muscles of the larynx, from irritation, as one of the causes of death. 262 diseases of children. Symptoms.—The coming on of the attack of pseudo-mem- branous croup may sometimes be recognized for three or four days, or even a Aveek. The child does not seem sick, and is playing about the house as usual, but has semie cold, anel the parents notice a slight hoarseness of voice and cough. AVe Avill notice, however, a peculiar metallic resonance to the voice, cry, and cough, but more especially that there is a dry and Avliistling respiration. This is so marked that the breathing may be heard across the room. The attack of croup most frequently comes on at night, as in the other cases. In the evening it is noticed that there is more hoarseness of the voice and the cough is someAvhat croupal, but as the child breathes pretty well and does not seem sick, the parents flatter themselves that it is but a cold, and will give no trouble. The mother has told me of going to the child's bed or crib, attracted by the peculiar whistling respiration, impressed that there Avas something wrong, but fearing ridicule if she sent for the physician. As time passes the child becomes restless from difficult breath- ing, has slight attacks of cough in his sleep, Avhich are clearly croupal. In another hour or two he aAvakes with a start anel assumes a sitting position, evidently suffering much from difficult respiration, Avhich is increased by the attacks of coughing. The symptoms are now very marked, the respiration is sibilant or whistling, and difficult; the cough hoarse and metallic; the voice roughened or sunk to a Avhisper, and the cry shrill and piping ; the skin is dry, the pulse hard anel increased in fre- quency; urine scanty, and the patient restless and uneasy. As the disease progresses there is a gradual increase of all these symptoms, but especially e>f difficult respiration, which is constant. The cough is spasmodic in its character, and Avlien it comes on the patient suffers very greatly from want of air. After a time evidences of asphyxia appear in the bluish lips, distended veins, leaden appearance e>f the surface, cold extremities, dullness of the nervous system, and finally coma and death. The entire duration of the final attack Avill be from six to forty-eight hours. Diagnosis..—That it is a case of croup is evidenced by the peculiar cough anel the change of the \Toice and cry; that it is pseudo-membranous croup by the constantly increasing difficulty croup. 263 of respiration, the marked dryness and sibilance in the sound of the air passing through the larynx, and in the peculiarly dry and metallic cough. Dryness and metallic resonance, in addition to the croupal cough and voice, are the diagnostic points. Prognosis.—The prognosis is not as favorable as in the other two varieties, and with the best treatment some cases Avill prove fatal. Still I should not be willing to indorse the old state- ment—"a large majority must die"—but think, with proper treatment, the majority will recover. Treatment.—The indications of treatment in this case are: To produce relaxation of the intrinsic muscles of the larynx, anel thus give freedom to the respiration, while Ave pursue the main treatment; to lessen inflammatory action, anel obtain free secretion of mucus, for the purpose of effecting the detachment of the false membrane; and finally to effect the removal of this. To fulfill the first indication, Ave employ inhalations of the vapor of water, or Avater and vinegar or lime Avater, as will be hereafter named. With this Ave direct the continuous applica- tion to the throat of flannel cleiths wrung out of hot water, in the meanwhile bathing the throat with the Compound Stillingia Liniment. These are important means, and should never be neglected. There are tAvo plans of accomplishing the seconel indication. The one is, by the use of tincture of Veratrum viride or Aconite, aieled by inhalations of lime Avater, anel is a very goe>d treatment and much pleasanter than the use of nauseants. I prescribe the Areratrum in the 'proportion of gtt. x. to water 5iv., a teaspoon- ful every fifteen minutes, until it produces a marked influence upon the pulse, then in smaller doses to continue its effect. Aconite is preferred when the pulse is small and frequent, and is administered in the usual small de>ses: Py Tinct. Aconite gtt. ij. water oiv., a teaspoonful every fifteen minutes. If the chihl is very sensitive to the action of the remedy the dose should be still further reduced, and if Avefind the lips dry anel contracted, and the child grasping at the mouth Avith its hands, it should be suspended and Veratrum substituted. If the tongue is pallid anel shows small spots of reel, Phyte>- lacca mav be combined with the medicine. If the little patient is dull and stupid anel wants to sleep, give Belladonna. If it has a sharp stroke of pulse, and moves its head restlessly back- 264 DISEASES OF CHILDREN. Avard and forward, throAving it backAvards as if it would bury the occiput in the pillow, give it Rhus. This remedy is also inelicated by the shrill cry, as if frightened, and sudden starting from sleep. Gelseminum is.indicated by the flusheel face, bright eyes, and contracted pupils, Avith reslessness anel great irritation. These remedies are secondary, it is true, but it is a case that re- quires all that Ave can de>, and if by one of these Ave strengthen the Aconite and Veratrum, Ave give our patient an additional chance. AVhat the physican needs, most of all, is a steady hand. The treatment requires time, and Ave must not get excited. If the patient is growing no Avorse, Ave should feel satisfied for a time ; if there is but a slow improvement, as marked by more ease of respiration, a better circulation, warmth and moisture of fet't, legs and forehead, Ave will feel encouraged and hold fast to the treatment. The use of lime water as an inhalation is a very important part e>f this treatment. It is claimed that it alone is sufficient to arrest the inflammatory action and cause the detachment of the membrane; and I have employed it with success when other means have failed. The Veratrum and Aconite also have proven very successful alone, and they will fulfill the first tAvo indications. The other and older plan of treatment is by the use of the nauseant emetics, and if properly used will give excellent re- sults. I may add, that if improperly used, i. e., so as to irritate the stomach with retching and ineffectual efforts to vomit, they will hasten the fatal termination. Of these remedies I prefer: ly Acetous Tincture of Lobelia, Acetous Tincture of Sanguinaria, aa. 5j., Molasses 5j., Chlorate of Potash, finely poAvdered 5ss., let them be combined with heat, and add the potash. AVe give this in doses of a teaspoonful every ten or fifteen minutes until nausea is induced, then in smaller doses so as to continue the nausea without vomiting. The greater and more constant the nausea Avithout efforts at vomiting, the greater the success of the treatment. Using the hot applications to the throat, and the inhalations of vinegar and Avater, Ave continue the nausea for some hours, at least until Ave have evidence of secretion, and the commencing detachment of the false membrane. This Avill readily be de- tected by the moist sound of respiration, and a gurgling flapping croup. 265 sound in the act of coughing. If the child is breathing pretty freely, Ave may Avait for the removal of the membrane by the cough, as it Avill be brought aAvay by shreds. But if, with the loosening of it, it seems to be draAvn upAvard in expiration, and downward in inspiration, tending to block up the passages, anel producing evident symptoms of asphyxia, Ave carry our remedies to thorough and prompt emesis. Generally it Avill be well enough to prepare an infusion of the compounel powder of Lobelia and Capsicum for use at this time, as Ave Avill have established a degree of tolerance for the other preparation. Occasionally Ave will meet Avith a case requiring prompt relief. Here the chilel may be turned on its abdomen, and a finger in- troduced into the mouth, draAving the tongue forward anel excit- ing the fauces, will be followed by a fe>rcible expulsive effort, and the membrane will be detached. A case of this kind oc- curred in my practice—the membrane became detacheel and en- tirely stopped the larynx, the child Avas asphyxiated anel Avoulel have died in five minutes. I snatched it from the mother, turned it on its face, inserted my finger as far doAvn as the larynx; a forcible effort at vomiting ensued, and the Avhole membrane Avas removed at once, being a perfect cast of the larynx. The child recovered. Success in the treatment of pseudo-membranous croup, what- ever means may be pursued, depends upon keeping the larynx relaxed to permit aeration of the blood, until in the course of time Ave get the detachment of the false membrane. It demands patience anel perseverance in the use of the means named, and success Avill follow. The convalescence of such a case demands much care, as the patient Avill have suffered from imperfect respiration, from the effects of the remedies employed, and the larynx and other mu- cous surfaces Avill be in a debilitated condition. Put the patient upon the use of bitter tonics, as: Ty Quinia, Hydrastine, aa. gr. vj., make twelve poAvders, give one every three hours. The chilel should be kept Avarm and quiet, in the recumbent position, anel guarded from draughts of air, and in addition it should be kept free from excitement. 266 DISEASES OF CHILDREN. SPASAIODIC CROUP. In some sections of country this is the common form of croup, though in others the mucous form is of most frequent occurrence. It is not so severe, anel ordinarily patients recover Avithout difficulty. Very rarely a case is met with running to a fatal termination. Causes.—The cause of this, as of the other forms, is cold, sudden change of temperature, exposure to an east or north wind, sitting in a draught, irritation of the digestive apparatus, etc. Pathology.—In spasmodic croup there is irritation of the mucous membrane of the larynx with determination of blood, or in some cases a slight superficial inflammation. The irritation is sufficient to excite spasmodic contraction of the muscles of the larynx, hence the symptoms of croup. In many cases the irrita- tion extends to the bronchial tubes as well, and they are more or less contracted. Thus, while the difficulty of breathing is prin- cipally laryngeal, it may be to a limited extent asthmatic. Symptoms.—In this case there is usually but slight symptoms of cold before the attack, though occasionally the child will have a severe cold. Frequently there is slight hoarseness in the even- ing and a little cough, though not sufficient to attract attention. The child is put to bed and sleeps for an hour or tAvo, then be- comes restless, and finally Avakes with a start, suffering severely from difficult breathing. Noav the breathing is stridulous, the cough hoarse and croupal, the voice hoarse or Avhispering, and the cry shrill and piping. The skin is soft anel moist, the pulse soft and regular, and the nervous system sIioavs no traces of excitement. In a feAV minutes the child breathes easier, and may fall asleep, but the period of ease is short, a paroxysm of cough occurs, anel the breathing is as difficult as before. Thus the disease Avill continue for hours, broken up into exacerbations and remissions, until finally, the paroxysms becoming lighter anel lighter, the breathing is Avholly relieved, and nothing is left but a slightly hoarse cough. Diagnosis.—The diagnosis of spasmodic croup may be easily made if Ave notice, first, that there is an entire absence of febrile CROUP. 267 symptoms; second, that it is remittent in character and broken up into exacerbations and remissions. There is an absence of the mucous rattling, as in mucous croup, and the extreme dryness of respiration and cough, as in the pseudo-membranous; and neither in the respiration nor cough do Ave detect any evidences of change in the conelition of the mucous membrane, as is so distinct in the other tAvo forms. On the contrary, all the symp- toms point to irritation of the intrinsic muscles of the larynx, and the consequent diminution of its calliber, as the true condition. Prognosis.—The prognosis is favorable. For, Avhile in ex- ceptional cases, the impairment of respiration may be so great as to destroy life, in the majority recovery Avould occur Avithout aid from medicine. Treatment.—The treatment of mucous croup may be em- ployed in this case, especially the treatment by the use of nau- s.-ants. I prefer preparations of Lobelia to any other, as this is our most powerful anti-spasmodic. The compound tincture of Lobelia and Capsicum (King's Anti spasmodic Tincture) is a very good form, but almost any preparation of the remedy will ansAver. It should be given in doses sufficiently large to produce nausea, but ahvays short of emesis. In the milder cases the administration of the compound tinc- ture e>f oils of Lobelia and Stillingia (Stillingia liniment), in doses of one drop, repeated every quarter or half hour, with its external application to the throat, will be sufficient to arrest the disease. In giving this, it is dropped on sugar, Avhich is allowed to dissolve in the mouth anel SAvalloAved Avithout Avater. This will also be found a good treatment in the milder cases of mucous croup, or in its earlier stages. In families where the children are subject to croup, it will save much trouble to provide the mother with the remedy, Avith directions for its use. It Avill save many unpleasant trips at night, and be a very great satisfaction to the parents. Spasmodic croup is frequently sympathetic, and repeated at- tacks occur much to the surprise of the physician. There is an irritation of the stomach requiring treatment, or the patient wants sulphite of soda or sulphurous acid to remove an unpleas- ant coat from the tongue, (and a similar unpleasantness from the stomach), or it may be troubled with worms aud require Santonine with Podophyllin. 268 DISEASES OF CHILDREN. In some of these cases the disease is distinctly periodic, and quinine should be given in full antiperiodic doses. In other cases the reccurreuce of the disease is prevented by the adminis- tration of Bromide of Ammonium oij - Avater 5iv., a teaspoonful every four hours. In still other cases the croup is the result e>f a suppressed eruption, frequently urticaria or hives, or it may arise from retro- cession of an eruption, and erythema, roseola, or even that which is popularly known as heat. These cases will be reached by the administration of small doses of Aconite with Belladonna, and sometimes by sponging the surface Avith hot water. (EDEMA GLOTTIDIS. (Edema glottidis, or asthenic laryngitis, may occur at any age, but is most frequent in childhood. It is not met Avith very fre- quently ; indeed, many physicians will practice a life-time without seeing a case. Causes.—This disease seems to be dependent upon colel, but why it should -invade this particular part Ave are unable to tell. As it occurs in feeble children, and therein manifesting a ten- dency to disease of the throat, it is probably OAving to debility of the tissues. Pathology.—The disease is undoubtedly inflammatory in its character, but the inflammation is subacute, and involves the submucous tissue. In its progress there is effusion into this, and it becomes SAVollen, and where this tissue is loose, as the iinvard surface of the epiglottis, and the upper portion of the larynx, it produces such engorgement as to obstruct the passage of air. As this distension is greatest in the epiglottis, the difficulty is much greater in inspiration than in expiration. Symptoms.—The disease commences with a continually in- creasing impediment to respiration, and a feeling of fullness anel constriction, and continuous desire to clear the throat, as if the irritation Avere caused by some foreign body. The voice becomes hoarse, then croupal, and afterward sharp, stridulous, Avhispering, and is then lost entirely. There is a hoarse, convulsive cough, with fits of suffocation, causing great agony. CEDEMA GLOTTIDIS. 269 The most marked feature of the disease is, that while inspira- tion is prolonged, stridulous, and exceedingly difficult, expiration is comparatively easy. This feature is so constant as to be path- ognomonic. There is no fever, but as the disease progresses the pulse be- comes more frequent, small, and irregular. The difficulty of breathing increases, the paroxysms of coughing and suffocation are more frequent, symptoms of asphyxia appear, the cerebral functions are disturbed, and at last death ensues from inability to inflate the lungs. Diagnosis.—The diagnosis in this disease will be readily made, if it is recollected that the difficulty is in inspiration, while expiration is comparatively free. In the later stages of the dis- ease, when it is likely to prove fatal, the diagnosis will be more difficult. Prognosis.—In the early stages of the disease, the prognosis is favorable; but Avhen symptoms of asphyxia begin to appear, it is doubtful. Treatment.—The treatment of this case will be wholly different from that adopted in croup, being stimulant instead of relaxing. We would dry cup the throat and upper part of the back, and repeat it if the case Avas serious; applying to the throat and breast a cloth spread Avith lard and sprinkled with the compound poAvder of Lobelia and Capsicum, changing it two or three times daily. A mustard foot-bath may be used Avith good effect, and repeated tAvo or three times, fenlowing it by the application of dry heat. AVe guard against coldness of the ex- tremities, which so frequently follows the ordinary use of the fe)ot-bath, and which almost invariably increases the disease. If the pulse is frequent and small, Ave will give Aconite, com- bining Avith it Apocynum, as: Py Tinct. Aconite gtt. ij. to gtt. v., Tinct. Apocynum gtt. iij. to gtt. xv., water Si v., a teaspoonful every hour. Apocynum Avill act upon the bowels in quite small doses, but if the bowels are torpid the proportion of this remedy may be increased. Phytolacca is sometimes indicated by the soreness of the mouth and throat, and engorgement of the lym- phatic glands. Belladonna is a good remedy in some cases, the indication being the dullness anel stupor, and inclination to sleep. In some cases stimulant doses of Lobelia, with some pleasant 270 diseases of children. aromatic to prevent nausea, may be prescribed. The following formula answers well: ly Tincture of Lobelia oij, Compound Tincture of Lavender f5ss., Simple Syrup to 5ij-; a teaspoonful every hour, or, better, half teaspoonful every half hour. If at any time it should produce nausea the dose must be lessened. This may be aided by the use of stimulant inhalations with the spray apparatus. A very good inhalation may be formed by adding Carbolic Acid, grs. v., to Avater 5iv-> or, Hydrochlorate of Ammonia, grs. x., to water Siy-; or in place of them, lime water, of full strength, may be employed. Associated with these means, in a malarial country Ave would give quinine in stimulant doses, say half to one grain every three hours. It may be given alone, or, what is better, associated with hydrastine. Sometimes we find a very troublesome cough, that greatly in- creases the patient's danger, by its interference Avith the respira- tory movement. AVithout the cough the child Avould get a suffi- cient supply of air, and its blood would be decarbonized; with the Cough it suffers from defective oxygenation and retained car- bonic acid. In this case the life of the patient may depend upon quieting the cough. For this purpose I Avould make the folloAV- ing prescription : Ty Sulphate of Morphia gr. j., Alum 5ss., Gum Arabic, AYhite Sugar, aa. 5i-; mix and divide in twenty parts. One of these may be placed upon the tongue, and allowed to dissolve, and be swalloAved without taking fluid, and repeated as often as may be necessary to quiet the irritation. BRONCHIAL CATARRH. This is one form of cold—that in which it principally affects the bronchial tubes—as in nasal catarrh it is principally confined to the cavities of the nose. It is of frequent occurrence in the fall and early winter, and in the changeable weather of spring. Sudden changes of temperature, or the barometric condition of the atmosphere, is a very common cause. Exposure to north or east Avinds, or too long or great exposure in cold AA'eather, will also cause it. Pathology.—The disease varies from simple irritation with determination of blood, to a slight grade of inflammatory action. In all cases there is a stage in which secretion is arrested. This, BRONCHIAL catarrh. 271 hoAvever, is short, and when the patient is seen by the physician, increased secretion is a present condition. Symptoms.—The child manifests the usual symptoms of cold, and in addition has a cough, with some difficulty of respiration. It is noticeel that it eloes not feel so Avell as common, that it does not move freely, or if eating, that its appetite is impaired. There is ahvays more or less febrile action for tAvo or three days, and sometimes the fever is so prominent for a day or tAvo that it ob- scures the symptoms of local elisease. The physician notices in addition to all this, that there is a want of free respiratory movement, and an unnatural rattling sound in respiration. On auscultation Ave find the evidence of increased mucous secretion over all parts of the chest, in the moist bloAving sound (mucous rhonchus). After the third or fourth day, the febrile action passes away, the difficulty of breathing goes Avith it, leaving but the cough, and increased secretion, Avhich gradually declines until in from ten days to tAvo Aveeks, it has wholly disappeared. Treatment.—In the earlier stage of the disease Ave give Aconite or Veratrum, according as the pulse is small or full, Avith such other remedies as may be inelicated. If the patient seems to have pain in the chest, on coughing or in respiration, Bryonia is suggested. If the pulse is sharp, and there is rest- lessness Avith sudden starting in sleep, the remedy will be Rhus. If there is much mucous secretion, anel rattling in bronchial tubes, Avith suppressed breathing, Lobelia is added to the seda- tive. In some cases the old prescription—ly Tinct. Lobelia oj., Comp. Tinct. Lavender oiij , Simple Syrup ojss.—is a most excel- lent remedy ; it can be given in small doses, frequently repeated, just short of nausea, until the patient is relieved. If there is much oppression of the chest with difficult respira- tion, use the cloth spread Avith lard, and sprinkled with the compound poAvder of Lobelia and Capsicum, applying it to the entire anterior and lateral Avails of the chest, and changing tAvo or three times a day.' 272 diseases of children. ASTHENIC BRONCHITIS. A form of bronchial disease is met with in young children, which Ave have been accustomed to describe under this head, though it does not express the conditions as well as we would wish. Causes.—The exciting cause of the disease is colel, from ex- posure, from sudden changes of temperature, or of the hygro- metric condition of the atmosphere. The predisposing causes are such as impair the general health of the patient: bad air, insufficient diet, Avant of cleanliness and the condition heretofore describee! under the head of dyscrasias—bad blood and imperfect nutrition. Though the elisease most frequently occurs in such persons, it Avill occasionally be met with in children who have been healthy, and avIio have all the care and comforts that can be given them. « Pathology.—The inflammation of the bronchial mucous membrane is of a Ioav grade, and is folloAved by relaxation and a sluggish circulation with increased secretion. It is this loss of irritability of the bronchial muscular fiber, Avith the greatly in- creased secretion, that is the principal source of danger. Symptoms.—This is the peripneumonia notha of authors, and generally occurs in very young or old persons, or in those of exhausted constitution, or who have been liable to coughs with profuse Avatery expectoration. It usually commences with symp- toms of cold and oppression in the chest, with slight febrile reaction. The cenigh is severe, occurring in paroxysms; the breathing is oppressed, laborious and wheezing; the expectora- tion, scanty at first, soon becomes abundant, thin and frothv ; the pulse is quick, small, and irregular, the heat of the surfiice but little if any increased, the extremities generally being ceiol ; the tongue is loaded with a foul, dirty mucus, the appetite is gone, and the bowels constipated at first, become irregular as the disease advances. As the disease becomes more intense, the countenance is pale and anxious, there are exacerbating fits of dyspnoea, in Avhich it seems almost impossible for the patient to breathe, and if the patient attempts to take a full breath to relieve this, or changes his position, a severe fit of coughing is asthenic bronchitis. 273 brought on, sometimes terminating in vomiting Avhich gives temporary relief. If the case terminates fatally, the tongue be- comes livid, the face dusky, the patient can not lie down, and if he sleeps it is but fe>r a few moments, and wakes threatened with impending suffocation ; delirium sets in, with cold and clammy perspiration, and the system is soon exhausted. In Aveak ami poorly nourished children, this disease is of fre- quent occurrence. At first it is noticed that the little patient has a protracted chill, fed lowed by febrile exacerbation. The fever is higher in the afternoon, but becomes less and less marked as the disease advances. Respiration is quick and Avheezing, the pulse freepient ami full, though soft and easily compressed. The cough is persistent, deep, ami IioIIoav ; the expectoration, at first a viscid mucus, becomes, as the disease advances, yellowish, greenish, and opaque. Dyspnoea is marked when the disease is fully de\7eloped, and coming on in pare)xysms it is followed by a long harassing cough, Avhich frequently terminates in vomiting, giving relief for the time being. The disease sometimes con- tinues for days, or even we'eks, terminating favorably ; or the dyspnoea becoming more intense, Ave observe symptoms of asphyxia rapidly increasing, and the child dies of apnoea. Diagnosis..— AVe form our diagnosis in this affection, by the Ioav grade of febrile reaction, marked derangement of function, and prostration, that the inflammation is asthenic ; by the cough and difficulty of respiration, that the respiratory organs are the seat of the disease ; and by the presence of the mucous rhoncus and resonance on percussion, that the bronchial tubes are the parts involved. Prognosis.—When the disease is mild, a favorable prognosis may be given, but Avhen severe, it is an exceedingly dangerous affection, anel our prognosis must be guarded. Treatment.—In young children I invariably pursue the one course, and thus far with success. Taking a soft cotton cloth, sufficiently large to cover the anterior and lateral Avails of the chest, it is spread evenly Avith lard, and dusted with the com- pound powder of Lobelia and Capsicum (emetic powder of the Dispensatory) ; this is applied to the chest and changed two or three times in the twenty four hours. Internally I prescribe: 18 274 DISEASES OF CHILDREN. R> Tincture of Lobelia 5j-> Compound Tincture of Lavender oij-, Simple Syrup 5jss., M.; half a teaspoonful every thirty minutes until the breathing becomes easier, then every hour. In all of these cases it is necessary that the child be kept quiet and Avarm; and I ahvays prefer that it be kept in the cradle or crib, rather than in the mother's or nurse's arms. Keep the ex- tremities Avarm—close attention to this, will in many cases be the difference betAveen a successful or fatal termination. Hot flannel to the lower part of the body, with dry heat in the form of bottles of hot Avater, will fulfill this indication. In older children when the pulse is frequent, I give small doses of Aconite to give strength to the circulation. It will be observed that as the pulse becomes less frequent under its influ- ence, it attains strength and volume. In some cases the dull- ness and hebetude, tending to coma, will be an unfavorable symptom. Here I would add Belladonna, using it in doses heretofore named. Other remedies may be indicated, for the disease presents many phases. I have-seen cases where the hot sponge bath, stimulating the skin, or even where* the addition of a small portion of hydrochlorate of ammonia to the hot Avater was an important means. Others are markedly benefited by the quinine inunction. AVe always have, the therapeutic maxim clearly before us, " that without reference to the name of the disease, whichever remedy is indicated is to be employed." ACUTE BRONCHITIS. Acute bronchitis is of frequent occurrence in childhood, and forms the larger part of those cases Avhich are known as lung fever, and winter fever. In general it does not present those acute features that are noticed in the sthenic bronchitis of the adult, but many cases will be quite severe. Causes.—Inflammation of the bronchial tubes arises from the same causes that produce inflammation in other tissues. Exposure to cold, especially to the north or east Avind, sudden changes of temperature, etc., are the common exciting causes. The predisposing causes are all such as impair the general health; and as a rule, it may be stated that such causes will not ACUTE BRONCHITIS. 275 j>roduce inflammation unless the vitality or resisting poAver of the system is lowered from other causes. Pathology.—The inflammation is confined to the bronchial mucous membrane, and in some cases involves but a portion of it, but in severe cases it extends to all the bronchial tubes. At first there is determination of blood, and the tissue is injected, swollen, and dry, but afterward there is impairment of the cir- culation and increased secretion. AVhen children die of the disease, post-mortem examination shows the mucous membrane thickened and softened, and the bronchial tubes more or less clogged with accumulated mucus and muco-pus. Symptoms.—For a day or tAvo the child has symptoms of cold, with some cough. This is succeeded by a chill, sometimes scarcely noticed by the mother, but lasting from one to four hours. FolloAving this, febrile reaction comes up briskly ; the surface becomes hot and dry, the pulse is hard and frequent, and the child irritable and restless; the urine is scanty and the boAvels constipated', the tongue having a pretty uniform Avhite coat. The fever gradually increases to the third or fourth day, remains stationary for from one to four days, and then declines as the inflammation passes off. AVith the first coining on of febrile reaction the attention Avill be attracted by the irritative cough, that repeats itself every few minutes. It is not yet the full bronchial cough, that is so marked a feature after the third day, but is half way betAveen this and the hacking cough of pneumonia. The cough is dry and the respiration dry and whistling, ami Avhen the ear is applied OArer the chest, there is a marked sibi- lance or dry blowing sound. By the end of the second day Ave notice that there is slight secretion of a transparent, tenacious white mucus, streaked Avith blood. This is increased the third day, and by the fourth it commences to assume a yellowish, opaque appearance. Up to this time the secretion of mucus seems rather to increase the cou<*h, as it is a source of irritation and is raised with difficulty. AVhen secretion is fully established Ave have a moist, blowing sound, or raucous rhoncus, Avhich is very marked. After the sixth day, the mucus becoming yellow and opaque, it is raised with less effort, and the cough is not so hard or so frequent, and 2/6 diseases of children. respiration is much easier. From this time there is a gradual elecline in all the symptoms, and the patient is convalescent from the seventh to the fourteenth day of the disease. PuoGNe)sis.—Though a severe disease, Ave do not look upon it as a fatal one, though occasionally from its intensity it becomes difficult to manage. If secretion commences, becomes opaque, easily expectorated, with an abatement of the fever, the case is progressing Avell ; but if symptoms of imperfect depuration of the blood are developed, with delirium, the case is a grave one. During the disease, if the sputa changes from an opaque to a glairy white mucus, we may be satisfied that the inflammation is redeveloped in its original intensity. Treatment.—The treatment will be directed to lessening the frequency of the pulse and temperature, relieving the irritation and stopping determination of ble>od to the bronchia? and lungs, relieving irritation or other Avrongs of the neiwe centers, and establishing secretion. It is Avell to have the subject thus clearly in mind that Ave may be able to make our diagnosis and select our remedies. Quite as essential is it that we know Avhat not to do, and what to keep friends from doing. AVe do not propose that the stomach or bowels of our patient shall be irritated by cathartics or nau- seants, and Ave object to the teas and potions that friends are inclined to give or insist upon our giving. To control the pulse Ave administer Aconite, if the pulse is small and frequent (Aconite is the child's sedative), Veratrum if it has volume and is frequent. They are both good remedies, and relieve irritation of the lungs and bronchia? as well as the general irritation Avhich gives the frequency of pulse. If the patient suffers pain, (this may be known by the expres- sion of the face and the cry,) Bryonia should be added to the sedative. If the patient has a persistent cough with whistling in the smaller bronchiae, and further on, if there are blowing sounds Avith free secretion, Ipecac should be employed. If there is an oppressed respiration, with abundant mucous secretion after some days, Lobelia is the remedy. A very hot skin, but seem- ing almost on the point of breaking out into a perspiration, and a full, oppressed pulse, calls for Eupatorium perf. The remedies that relieA-e wrongs of the nerve centers are ACUTE BRONCHITIS. 277 suggested by symptoms that force themselves upon our notice. The extreme restlessness, sensitiveness to impressions, evidences of pain, sleeplessness, with flushed face, bright eyes, contracted pupils, and increased heat of the head, call for Gelseminum. The same restlessness and irritation, but with contraction of the frontal muscles, sharp pulse, and reddened papillae at tip of the tongue, call for Rhus. The dullness and inclination to sleep, Avant Belladonna. In aeldition to the remedies Avhich influence the pulse, and re- lieve irritation of the nerve centers, Avhich also lessen the tem- perature, Ave employ baths to lessen the heat e>f the body and improve the functional activity of the skin. The bath may be soap and Avater, the alkaline bath (bicarbonate of potash is the best), the acid bath, or fatty inunction. The temperature of the bath is to be determined by the condition of the patient, as here- tofore named. If the temperature is high, and inflammation acthTe, a cold pack may occasionally be used Avith great advantage—even an entire Avet-sheet pack is a good thing. In the majority of cases, hoAvever, a hot pack is best, and may consist of three or four thicknesses of flannel Avrung out of hot Avater, and applied to the chest over a single thickness of flannel which is alloAved to remain. Sometimes sponging the chest Avith hot water for a feAV minutes, and then covering it with flannel, exerts a good influ- ence. My favorite local application, hoAvever, and one that is ahvays safe, is the soft cloth spread with lard, and sprinkled Avith the Compound PoAvder of Capsicum. This may be reneAved twice a day, scraping the old off with a knife ami respreading. If the irritation of the bronchia? is so great as to cause much difficulty of respiration, or if the cough should be so harassing as to prevent sleep and aggravate the fever, Ave may relieve the patient by the use of inhalations. The steam atomizer is an ad- mirable apparatus in this case, but if not at hand Ave will impro- vise an inhaling apparatus out of a half gallon cup and a hot iron. The vapor of Avater alone is sufficient in most cases ; co- in some Ave may use an infusion of hops, of tansy, of poppy heads, or a small portion of tincture of opium may be added. The inhalation may be repeated as often as every one, two or three hours, until the patient has relief. The plan laid doAvn I think much better than the old method by the use of nauseant expectorants, and while a case might 278 DISEASES OF CHILDREN. occasionally arise in the adult, Avhere I Avould use the old method, I do not think I Avould employ it in the child. CHRONIC BRONCHITIS. AVe occasionally meet with a case that may be classified as chronic bronchitis, though it does not present all the symptoms of that disease in the adult. Like the disease in the adult, it is associated with an impairment of the general health, and may terminate in infantile phthisis. Causes.—The cause of this bronchial disease in the chilel is the frequent repetition of bronchial catarrh from cold. At first the patient recovers from the attack well, but as it continues to be repeated the recovery is tardy, and less and less perfect, until finally Ave have the condition of the respiratory organs under con- sideration. In other cases the disease is the sequel of measles. Pathology.—The disease is not strictly a chronic inflamma- tion, but rather a condition of the mucous membrane resembling that produced by such inflammation. The nutrition of the mu- cous tissue is impaired, the circulation is sluggish, the tissue thickened, ami there is an increased mucous secretion Avhich clogs up the bronchial tubes. In the severer cases, the secretion is muco-pus, and may be in considerable quantity and quite offensive. Symptoms.—The child has lost flesh and strength, and has a pale or suIIoav appearance. The pulse is feeble, the extremities become cold easily, the appetite and digestion are impaired, the bowels irregular, and the child is fretful and peevish, as Ave should expect under the circumstances. Our attention is called to a bad cough, from which the child has suffered some Aveeks, and which has been very intractable. AAre notice that it is loose and someAvhat IioIIoav, and that more or less mucous is brought up by the act of coughing, but gen- erally swallowed. Applying the ear to the chest, Ave hear a very marked moist bloAving sound—indeed, Avhen secretion is free, it had better be called a gurgling or rattling—as the air passes into and out of the lungs. As the disease progresses, the child becomes feebler, its appetite and digestion more impaired, and the cough worse. It has chills, CHRONIC BRONCHITIS. 279 folloAved by hectic fever, during Avhich it is irritable and restless, and finally the strength is so exhausted that it dies of inanition. Treatment.—The treatment of this case requires considerable care, and all harsh and unpleasant remedies should be avoided. There are tAvo principal objects in vieAV—to modify the irritation and lessen the cough; and to improve the appetite and digestion, and thus get better nutrition and restore the structure of the part affected. If both can be accomplisheel by one class of remedies it will be best, as the child's stomach is easily irritated, and will not tolerate too much medicine. Frequently we Avill attain the ob- ject by the use of Collinsonia alternated Avith tincture of muriate of iron- and glycerine; it may be prescribed in the following form: Py Tincture of Collinsonia 5'j , Simple Syrup 5ij.; a half teaspoonful three times a day. The preparation of iron may some- times be changed for the compound syrup of the hypophosphites. Occasionally we may require something more for the relief of the cough, in the earlier part of the treatment. Here I like the action of an infusion of clover hay, SAveetened and given as required. Or in place of this the Stillingia Liniment may bo given in doses of half to one drop on sugar, every three or fernr hours. AVhen the disease has arisen from measles, the Drosera will be found a valuable remedy, in the proportion of gtt. x. to gtt. xv. of the tincture to Avater §iy-; a teaspoonful four times a day. In some cases Veratrum and Bryonia seem to exert an excel- lent influence in quieting bronchial irritation, checking the cough, and improving the general health. In other cases Ave employ Arsenic, as—R> Tinct. Veratrum, Fowler's Solution of Arsenic, an. gtt. v., Avater 5iv.; a teaspoonful every tAvo or three hours. Rumex h sometimes an excellent remedy for cough, gtt. v. to gtt. x. being added to Avater 5hr- and gh'en in teaspoonful doses. If there is a very free secretion of mucus, Avith much rattling in the chest, Lobelia with Compound Tincture of Lavender may be employed, as heretofore named. For further information, the reader is referred to my Practice of Medicine, article "Cough." Inunction Avith quinine is an excellent measure in those cases in which there is feeble innervation or impaired circulation. Generally fatty inunction serves a better purpose than the ordi- nary use of baths; the surface being rubbed freely with the hand or Avith flannel. 280 DISEASES OF CHILDREN. Exercise in the open air, the free admissiem of light and sun- shine to the room, and a nutritious diet, are important aids to the cure. PNEUMONIA. Inflammation of the lungs is met with most frequently during ? the winter months, and like acute bronchitis it forms a portion of those cases knoAvn as lung or winter fever. In some localities it is a very common disease, but in others it is seldom met Avith. From Avhat I have noticed I should judge it to be most common in localities exposed to north and east Avinds, or indeed to any Avinds, and rare in sheltered places, as byAvoods, hills, etc. Thus in Cincinnati, aAvay from the river, it is rarely met Avith, but on high grounds we occasionally see cases. On the prairies e>f Illi- nois, and in Northern Indiana, Ohio, and New York, it is of fre- quent occurrence. Causes.—The common cause of inflammation of the lungs in children is cold, either from direct exposure, or from sudden alternations af temperature. Pathology.—In this case the inflammation is of the paren- chyma of the lung. In some it will progress as in the adult, embracing all of that part of the lung which is the seat of inflam- mation. But in the majority of cases it is confined to the lobules, and is thus scattered through a large portion of one or both lungs, sound lobules being interspersed betAveen the inflamed ones. From this character of the disease it has received the name of lobular pneumonia. For the first tAvo or three days the lung presents the appear- ance of determination of blooel, the capillaries being full, and the tissue consequently reddened; the lung still floats on water, though not so freely as the healthy tissue. From this time there is a continued increase in its density, the air-cells being effaced by the engorgement of the capillary vessels, and by exudation into the intercapillary spaces, and into the air-cells. This is the stage of red hepatization, and is fully completed by the sixth dav. Noav, in the majority of cases, resolution commences, anel the circulation is gradually restored from the circumference to the center, the effused material being taken up as soon as the blood begins to Aoav freely. Thus the lung is free of both the arrested PNEUMONIA. 281 circulation and the effusion, and becomes again permeable to air. Ri'solutiem is usually complete by the ninth dav. But should the inflammation run so high as to impair the vitality of the tissues, then the condition of gray hepatization may ensue. In this the effused material is formed into pus, and in a still further advanced stage, the tissues losing their vitality, soften and are likeAvise transformed. If we examine a lung in this condition, Ave will find it soft and friable, and readily lacerated by the fingers. The cut surface presents a yelloAv mottled appearance, and when pressure is made upon it an imperfect purulent fluid exudes. In a still further advanced stage small abscesses are formed in the lungs at the site of the diseaseel lobules. Symptoms.—Usually the child sIioavs symptoms of cold for tAvo or three days before the attack, anel is restless and fretful. In many cases the commencement of the inflammation is an- nounced by a persistent hacking cough, Avhich seems to arise from irritation of the throat or larynx. AVhat is peculiar about this cough is, that it seems to be made by the child, and fre- quently it Avill be scolded for persisting to cough when it seems to be unnecessary. Such a cough is ahvays annoying to the per- sons in the room for its persistency. Of course there are many cases in Avhich an ordinary cough follows the invasion of the in- flammation, and does not precede it as described. In all cases there is a chill, but in most it is so mild that it is scarcely noticed by the parents. In the majority, febrile reaction comes up slowly, and for the first twenty-four hours the child does not seem to have more fever than Avould attend an ordinary bad cold, but even in those cases it Avill be noticed that the cheeks are flushed, that there is too great dryness of skin, and sharpness and hardness of the pulse, fe>r a slight disease. In other cases the fever comes up rapidly, and runs very high. By the third day of the disease, a casual observer Avould notice that the child was quite sick. The skin is hot and dry, the pulse frequent and hard, urine scanty, bowels constipated, no appetite, a coated tongue, one or both cheeks flushed, and some difficulty in respiration. The cough is usually paroxysmal, and varies from the hacking cough first named to a deep bronchial cough. In semie cases the child is irritable and restless, but in most lies quite still, even though it suffers, and sleeps Avith its eyes partly open. 282 DISEASES OF CHILDREN. AVith these symptoms but little changed, the disease continues to the sixth day, Avhen, in a majority of cases, we find an amend- ment. The skin is less dry and hot, the pulse softens and is less frequent, secretion is gradually establisheel, the difficulty e>f respiration and cough passes away, and by the ninth day the chilel is free from fever and convalescent. AVhen it passes into the stage of gray hepatization, the pre>s- tration becomes alarming. The mind wanders, and in a short time coma comes on, and, gradually deepening, is attended with evidences of imperfect aeration of the blood, from which the child dies. Occasionally a very severe case is met with, in which evi- dences of asphyxia are manifested as red hepatization advances, and in which the disease will terminate fatally before the sixth day, on account of the extreme engorgement. Anel in very feeble children there is occasionally a case in which the deter- mination of blood is folioAved by congestion, and such engorge- ment of the lungs is produced in a feAV hours, that death results. This resembles the pulmonary apoplexy of the adult. Diagnosis.—The symptoms above named, cough and difficult respiration, point to the lungs as the seat of disease, Avhile the febrile reaction evidences its inflammatory character. Ausculta- tion during the first three days detects a marked change in the respiratory murmur, which is roughened and louder, and asso- ciated Avith a marked blowing sound, at first dry, aftenvard moist. From the third to the sixth day the respiratory murmur becomes less and less marked, until at last it is scarcely heard over the seat of inflammation, but is replaced by a moist bloAving sound (mucous rhoncus). With this change there is increasing dullness on percussion, though it is rarely so marked as in the adult. AVe have less evidence of diseased action from the sputa than in the adult, for children can rarely be induced to spit out the secretion removed by coughing. At first there is dryness of the mucous membrane; in tAvo or three days the secretion is Avhite, tenacious, anel has the globular form so characteristic of the dis- ease in the adult; about the fifth day it acquires a reddish-broAvn tinge, but rarely has the rusty hue that is seen in the adult. After this time, if coiwalescenee progresses, it becomes yelloAvish, and resembles the sputa of bronchitis. PNEUMONIA. 283 pRoe;NOSis.—The prognosis in the pneumonia of children is favorable, the mortality being but little increased over remittent fever. This, of course, is supposing that the patient has proper treatment and gooel nursing. Those cases that manifest symp- toms of asphyxia early, are to be regarded as unfavorable, as are those in which the disease progresses unabated beyond the seventh to the ninth dav. Treatment.—The treatment of pneumonia in the child should be quite simple, as it is not a case that will be benefited by or bear much medication. The indications are plain—to lessen the frequency and obtain a uniform circulation of the blood, to allay irritation of the lungs, and to establish secretion, and this is done in the order in which they are named. To accomplish the first object avc prescribe the special seda- tives, Veratrum anel Aconite, in the usual doses, repeated every hour. If the fever runs high, and the pulse is full and hard, the dose of the Veratrum may be doubled until it influences the pulse. All Ave expect of the remedy is that it will hold the febrile action and the inflammation in check, and after twenty- four or forty-eight hours Avill cause a gradual decline in both. That action of Veratrum Avhich brings the pulse down in six or eight hours from one hundred and thirty beats per minute to eighty or seventy beats per minute, is not desirable, because it can not be maintained, and because it is opposed to nature's methods of cure. Ao-ain, Ave note the indications for other remedies which may O 7 * be added to the sedative solution or alternated with it. Bryonia is given if the child sIioavs evidences of pain in respiration or on coip>'hino-; Rhus, if there is contraction of the facial muscles, and a sharp stroke to pulse, which is small and frequent; Lobe- lia, if there is marked oppression in the chest, and difficult breathing; Gelseminum, if there are evidences of determination of blood to the brain; Belladonna, if the child is dull and in- clined to sleep a great deal; Eupatorium, if the pulse is full and oppressed, and perspiration is caused by coughing, notwithstand- ing the heat of skin ; Phytolacca, if patient complains of sore mouth and throat; Baptisia, if the face is full and purplish, the tongue anel lips shoAving the same color. AVhen the tongue is dirty—a yellowish, glutinous coat—sul- phurous acid exerts an excellent influence, and Avill sometimes be 284 DISEASES OF CHILDREN. nearly all that the patient Avill require. Occasiemally the sul- phite e>f soda is indicated, and more rarely the chlorate of pot- ash. A trituration of podophyllin (second decimal or first cen- tessimal), in doses short of an action upon the boAvels, will give good results in those cases showing fullness of face and tissues generally, and especially fullness of veins, Avhich should be noted. Cathartics as a rule are contra-indicated, and if the bowels are locked up, it is much better to use an enema to open them. Two, three or four days Avithout an evacuation of the boAvels, is not commonly injurious, at least it is much better than the irritated stomach and intestinal canal from physic. Ipecacuanha exerts a specific action upon the respiratory ap- paratus, removing irritation and stopping determination of blood. It has been used alone Avith marked success, being giAren tritu- rated Avith sugar in doses just short of nausea, or Avith slight nausea for a few hours and just short of vomiting. I employ it in tincture and combine it Avith Aconite gtt. v. to gtt. x., to Avater r^iv. As the disease advances, if there be a very free secretion, with much rattling in the chest, and difficulty of breathing from obstructed bronchial tubes, the preparation of Lobelia with Comp. Tinct. of Lavender, as named under the head of asthenic laryngitis, will ansAver a most excellent purpose. In this case the cloth spread with lard anel sprinkled Avith Compound PoAvder of Lobelia should not be neglected. To fulfill the second indication Ave apply a hot fomentation as heretofore named, or the " mush jacket;" or in young children, where this Avould be inconvenient, the cotton cloth spread Avith lard and sprinkled lightly with emetic poAvder. The mush jacket is made of corn mush of ordinary consistence, spread an inch thick on cloth large enough to cover the anterior and lateral portions of the chest, and covered Avith musquito-bar, netting, or other thin goods, to retain the poultice. It is applied hot, a thinkness of flannel being first laid over the chest, and changed twice daily ; the heat is retained by the thickness of the poultice, and by keeping the body Avarmly covered. The hot application should not be continued longer than the first day, and then if needed replaced by the Lobelia and Capsicum. In all cases the air of the room should be kept moist, and if the irritation of the lungs is great, with harassing cough, we may obtain much advantage from the use of inhalations of the PHTHISIS PULMONALIS. vapor eif water, of an infusion of hops, or tansy, or poppy heads, or of one part of vinegar to three of Avater. This not only gives present relief, but it aids the cure; indeed, I am not certain but that the disease could be very successfully treated by the use of inhalations alone, adding the sedative to the Avater emph)yed. As a general rule, Ave Avill find the third indications of cure accomplished by the means alreaely named. As soon as the pulse is brought under the influence of the sedatives there is a natural tendency to a re-establishment of secretion. At the commence- ment of the treatment the patient has a gerieral bath with soap and Avater to cleanse the skin, and a hot foot-bath for its quiet- ing influence upon the nervous system. Further than this, I do not think bathing is beneficial, except sponging the surface under the cover, drying speedily and Avith friction. The child should be kept in the recumbent position in its cradle, crib, or bed, and should be kept pleasantly warm anel free from all draughts and changes of temperature. If at any time during the progress of the disease, there is tendency to coldness of the extremities, apply dry heat, Avrapping the feet and legs in flannel. If the child needs a stimulant and tonic, I think we may ob- tain the best results from the inunctionof quinine, as heretofore named. AVhen the disease passes into the stage of gray hepatization, Ave can do nothing more than support the strength by the use of the bitter tonics, as they can be given, and such food as we can pre\Tail upon the child to take. In some cases advantage might result from the use of sulphite of seala. PHTHISIS PULAIONALIS. Infantile phthisis is generally acute, resembling the hasty con- sumption of the adult. In this form Ave meet with it at all ages from the first weeks of life to the age of five or six years. After this time, phthisis pulmonalis is of very rare occurrence, until the age of puberty is past. Causes.—The predisposing cause is a feeble vitality, mani- festeel especially in the formation of blood and nutrition of tissue In this sense infantile phthisis is ahvays hereditary, as it is hardly possible that a child possessing normal vital or formative power 286 DISEASES OF CHILDREN. should have this disease, even under the most adverse circum- stances. The exciting causes are all such as still further loAver the vitality of the child. Diseases affecting the stomach and bowels, thus impairing digestion, or t'.iose Avhich impair secretion, loAver the vitality of the blood and its adaptation as a nutritive fluid. If uoav the child is exposed to the ordinary causes of cold, and ^ irritation of the respiratory organs is set up Avith determination of blood, the imperfectly formed albumen will be thrown out in the parenchyma of the lungs as tubercle. Pathology.—As above stated, a congenital defect of via- bility lies at the foundation of the disease, and as has been pre- viously stated, it is impossible for some children to live to adult years for this reason. This feeble viability is manifested in im- pairment of all the functions of the body, but especially in the formation of poor blood. This imperfect elaboration furnishes the material for tubercles, which only requires an arrest of secre- tion by which it is ordinarily removed, and a determination of blood to the lungs for its deposit in that tissue. Post-mortem examination sIioavs very extensive disease. In the early stage the lung is infiltrated with a yelloAV albuminoid material of cheesy consistence, and showing but very slight, if any, traces of organization. It resembles the lower form of yellow tubercle, as seen in the adult. This exudation does not Avholly prevent the entrance of air into the part diseased, for even Avhen the deposit is extensive, some lobules will be found free. At a further advanced period Ave Avill find this material in every stage of breaking doAvn, from that in Avhich it has softened to the ordinary consistence of pus, to that in Avhich the tissue of the lung has yielded, giving rise to large and ragged abscesses, containing the debris of the lung and the tubercular material. Symptoms.—The disease frequently commences as a simple cold, manifested by coryza, slight cough, seemingly from irrita- tion of the throat, impaired appetite, chilly sensations in the morning, Avith febrile exacerbations in the after part of the elav. The child is restless and fretful, and does not sleep well durino* the day, at its usual times. These symptoms continue for a AA^eek or ten days, thecoryza disappearing, but the cough increases, the chills are more marked, and the febrile reaction higher. PHTHISIS PULMONALIS. 287 Prostration becomes marked after a feAV days, ami the appetite is almost wholly lost. The patient is thirsty, and drinks often, especially at night, waking every hour or two. Its sleep is also disturbed, and it changes its position often, throAving off the cover, and frequently expressing its uneasiness in moaning and short cries. Thus week after Aveek Ave observe an increasing loss of flesh and strength, until the child is as much emaciated as in cholera infantum. And yet the cough is not very severe, neither is there much difficulty of respiration, or imperfection in the aera- tion of the blood. Still, these symptoms are sufficient to call our attention to the lungs as the seat of the disease. Quite fre- quently the blowing sound will be so marked that it is readily heard Avhen Ave sit doAvn by the side of the child. Upon auscul- tation it is found to extend to every part of the lung tissues. Diagnosis.—The marked emaciation and debility is evidence that the elisease, Avhatever it may be, is one affecting the forma- tion of blood and nutrition of tissue. If in the summer, Ave would suspect it to be one of the intestinal canal, but a careful examination determines that this is not the source of the lesion. The cough, some difficulty in respiration, anel the blowing or rattling sounds heard Avhen near the child, cause us to make an examination of the chest. On percussion Ave usually find a dullness over the superior lobes of the lungs, sometimes quite marked. But over the mid- dle and loAver lobes the resonance is clear, except in cases with congestion, when there is some dullness even here. On auscultation we find a uniform bloAving sound over the entire chest, with more or less mucous rattling, as there is more or less secretion. Though it seems louder in the sound lung, it does not mask the respiratory murmur which is heard distinctly. In those parts of the lung infiltrated with tubercle, the blowing sound is dull, as if deadened by passing through an infiltrated tissue, or the sounds are small, whistling, creeping in and out of the tissues, sometimes like a nest of mice. Not unfrequently the dry-crackling that so generally attends the same disease e>f the adult will be heard, though but for short periods. Prognosis.—The prognosis is unfavorable. The disease oc- curs in children of feeble viability, and who have little power to resist disease or of repair when this is arrested. Still, in some 288 diseases of children. cases, an infantile phthisis may be arrested, and by a proper res- torative treatment, aieled by good hygiene, a moderately good constitution may be developed in time. Treatment.—The treatment of this case can only be outlined, as the indications for remedies will vary, and here, as clscAvhcrc, Ave Avish the right remedy for the cemditions present, rather than a treatment for the name of the disease. AVith a frequent pulse and increased temperature, Ave think of Veratrum as a good basis of treatment. If there is pain in the chest, Bryonia is giATen for a feAV days, and is then replaced with Arsenic if the skin sIioavs atony; continuing in this Avay for a time, these remedies may be replaced with hypophosphite of lime alone, or with some preparation of malt given after meals. AAre can not, at first, use bitter tonics and restoratives by mouth with advantage, and we Avill therefore employ them endermically. The inunction of quinine, heretofore spoken of, Avill ansAver a very excellent purpose. Even simple fatty inunction Avill be found beneficial. If the parents can afford it as well as not, let the inunction be of good cod liver oil, Avith quinine in the pro- portion of 5'j- to the pint. Let the entire surface be thoroughly rubbed Avith this once or tAvice daily, using considerable friction. No exposure of the surface should be permitted at these times, but the child kept carefully covered. The fatty matter may be remoA^ed from the skin with a soft flannel. AVashing with Avater is absolutely prohibited, except the face and hands. The same directions for diet should be giATen as in a case of cholera infantum, and if there is irritation of the stomach anel boAATels, the same remedies may be used to relieve it. As the child improves, Ave may put it upon the use of tincture of muriate of iron and glycerine, as heretofore named, and sometimes Ave may add a small portion of the tincture of Nux Vomica to it. Probably a better restorative in this case will be found in the compound syrup of the hypophosphites, which is ne>t only very pleasant to the taste, but is easily appropriated. The de.se for a child tAvo years old will be one-third of a teaspoonful four times a day. Cod liver oil answers a very good purpose Avhen it can be taken. But with the majority of children under six, we will find it impossible to give it. DENTITION. 289 As the child becomes stronger, it should be taken out of doors Avhen the Aveather is warm, and the air calm ; and it should also be pe'rsuaded to use its limbs, and take moderate exercise. AVhen it can ne)t be taken out of doors, its chair or crib should be so placed that it may receive abundance of light, and even sunshine, if not too bright. CHAPTER VII. DISEASES OP THE DIGESTIVE APPARATUS. The digestive apparatus embraces the mouth, the throat, the stomach, and small and large intestines. The diseases Ave have to stiuly are those of the mucous membrane of these several parts, and of their functions. AVe take it for granted that dis- eases of mucous structure Avill demand a someAvhat similar treatment, no matter Avhat its location. If this vieAV is correct, we Avill have simplified the therapeutics of this class ofl diseases, and Avill also have made it more definite. DENTITION, AND ITS DERANGEMENTS. Dentition is usually regarded as the great trial of the health, if not of the life, of the child, and Ave find parents anel even physicians speaking of it as if it Avere a morbid process, instead of a physiological development. It is true that during the cutting of the teeth there is occasional disturbance, sometimes of one function, sometimes of another, but more frequently of the digestive tract. But the majority of these are but indirectly influenced by dentition, and the cause should be sought elseAvhere. The error is an important one, because it obscures real causes of disease, and prevents the direction of remedial agents for their removal. And Avith some persons it leads to interference with the natural eruption of the teeth, which proves injurious. As a general rule, the child exhibits evidences of buccal ex- citement about the fourth or fifth month. There is an increase of the salivary secretion, anel it has a strong desire to bite or press its gums strongly against Avhatever is given it. 19 290 DISEASES OF CHILDREN. This excitement continues to the eruption of the first teeth— the front incisors—Avhich occurs from the sixth to the eighth month. In some cases, the excitement becomes general, and there is restlessness and irritability of the nervous system, fe\Ter, derangement of digestion, and sometimes diarrhoea. The treatment of such a case is ATery simple. The child has a bath, and once or tAvice a day a hot foot-bath. AVe prescribe Aconite in the usual doses, and if there is much derangement of the stomach and bowels, small doses of an infusion of compound poAvder of rhubarb and potash, to produce a gentle laxative in- fluence upon the boAvels. Usually Avhen dentition is attended with such derangements, the subsequent cutting of the teeth will be attended Avith more irritation than the first. Especially is this the case in feeble children, at the eruption of the molars and canine teeth, during the second summer. But these cases need but the treatment just named, unless there is a distinct complication, which will be treated as noticed hereafter. Lancing the Gums.—Lancing the gums is an old practice, and is uoav someAvhat out of vogue. AVhen the lancet Avas the remedy for adult fevers and inflammation, lancing the gums Avas the remedy for all irritations supposed to arise from teething. Its use, therefore, Avhile sometimes beneficial, Avas frequently injurious. The eruption of the teeth through the gums is not a sudden nor a forcible process. As the teeth attain increased size they press upon the gum, Avhich is as gradually absorbed before them, and in the true physiological process there is no disturbance whatever. The lesiems Ave notice result from the deterioration of the child, induced by our abnormal civilization. The cases in Avhich the gums may be cut to advantage are those in Avhich there being the lesions of the nervous system and fever, that have been already noticed, there is marked SAvelling and lividity or duskiness of the gums, o\Ter the point where the tooth is to make its appearance. In such cases, occasionally, prompt relief folloAvs the incision of the gum, and the relief of its tension by the discharge of a small quantity of blood. It seems evident that it is the discharge of the blood which relieves the tension upon the parts, and in the same degree the irritation, and not the coming through of the tooth, as many persons think. DENTITION. 291 The tooth is cut none the quicker for the lancing of the gum. It has to come through by a process of growth, and this is a matter of time, so that days, and sometimes weeks, will elapse before it has fairly made its appearance. In lancing the gums a sharp knife, bistoury, or gum lancet, should be used, and the incision should be elirectly down upon the crown of the tooth. The lancet should not be cut against the tooth, hoAvever, so as to injure it, as it is yet delicate. Hemorrhage after lancing a tooth sometimes occurs, and I have seen two cases in which it proved fatal. Of course, these were exceptional cases, the children being of a hemorrhagic diathesis. Still, free and someAvhat persistent bleeding is not ■ uncommon. Occasionally the application of common salt or Avooel soot Avill arrest it, or a portion of spider's Aveb held on the incision for a feAV minutes with the fingers Avill ansAver the pur- pose. The most certain means of arresting hemorrhage in any such operation about the mouth, is the application of tanner's shavings to the part. It seems something like the crude medi- cation of centuries ago to recommend tanner's shavings or a cobAveb, when our materia medica is so full of astringents ; but a rather troublesome experience has taught me that such means are not to be rejected, Avhen found beneficial. In my own person I had hemorrhage for four days, from the extraction of a molar tooth, until, from loss of blooel, I could not maintain the erect position. All the ordinary means had been tried, Avithout any permanent effect, including the persistent use of persulphate of ii-on. The part was cleansed e>f clots, anel Avhile bleeding freely, the tanner's shaA7ings Avere applied, and in fifteen minutes it Avas Avholly arrested. Taking Care of the Teeth.—There are but ±ew parents who everthink of caring for the teeth of the child. They know they have to serve but a short time, and then be replaced Avith permanent ones. These milk teeth, hoAvever, serve just as im- portant a purpose with the child as with the adult. Their loss, I am satisfied, tends to injure the health of the child, as it im- pairs mastication, insalivation and digestion. Many a case of dyspepsia of the child three or four years old may be traced to this cause. As a means of preserving the teeth, I would recommend that the child be taught to wash the mouth Avith cold Avater, or Avater to which a small quantity of salt has been added. The decay of 292 DISEASES of children. the teeth is OAving in part to the decomposition of food between and adherent to the teeth, and if the mouth is thus cleansed after eating, this cause, at least, will be removed. The first permanent molars make their appearance about the third or four year, and are very commonly mistaken fen- tem- peu-ary teeth. These not uufrequently become carious, from the cause above named, from the sixth to the eighth year. AVhen this is the case, advise that the child be taken to a dentist, and have the teeth properly filled. Second Dentition.—The loss of the deciduous or milk teeth commences betAveen the fifth and the sixth year—or should com- mence at that time. There is a gradual absorption of the fangs of the teeth, as the permanent ones are developed beneath them. After a time they become loosened, so that sometimes they can readily be pulled out with the fingers. If not removed in time, the permanent teeth press them to one side, or forward, or back- Avard. This gives rise to present deformity, disease of the gum, and may so change the position of the permanent teeth as to occasion lasting deformity. AVhen it is noticed that they have become loe>sened, or that the permanent teeth are coming through, they should be extracted. This is but a little matter, as the teeth have mostly lost their fangs. I do not like the extraction of the deciduous teeth before this time, not only because the chilel loses the use of them, but be- cause the jaw-bone is sometimes imperfectly developed, in conse- quence, and Ave have irregularity of the permanent set. It is of importance that the permanent set of teeth be Avell- formed and properly placed, se) as to form a regular and uniform arch. It is not only a matter of good looks, but also of good teeth. It is my impression that if the general health of the patient is good, and it is furnished Avith the material for the formation of bone, in such form as it can appropriate it, the teeth will be regular and good. If a patient is presented to meshoAvingan irregular or deformed deMitition, I prescribe for the general disease, as if manifested by other symptoms of imperfect nutrition, the usual proportion of iron for children : R/ Tincture of Muriate of Iron oj., Glycerine 5h\, a teaspoonful three times a day. The hypophosphite of lime, or more frequently phosphate of soda, in small quantities, furnishes the phosphorus; Avhile a nutritious diet, properly se- STOMATITIS. 293 lected, (oat-meal is very good, so is cracked wheat,) and such hygienic means as seem to be necessary in the case, complete the treatment. AVhen the teeth are developed irregularly, as regards the arch, or overlap one another, or are angular, as it Avere tAvisted upon their axis, much may sometimes be done by simple means. AVhen a tooth is outside or inside of the line of the arch, pressure Avith the thumbs or fingers toward the proper place two or three times a day, Avill usually accomplish the object. Of course, in these as Avell as other irregularities, the deciduous teeth should be removed. Occasionally Ave Avill find a fang of one of these teeth overgrown by the gum so that it is not noticed. A careful examination dis- covers it, anel being removed, the cause of the deformity being gone, Ave find the teeth speedily assuming their proper position. The physician may instruct the parents as regards such man- ipulation, avIio will pursue it for some months, as the change is a very slow one. AVhen the deformity is greater than Ave can ex- pect to overcome by such means, Ave recommend that a dentist be consulted, Avho may apply such artificial support or pressure as will accomplish the object. STOMATITIS. Inflammation of the mouth in childhood assumes a number of different forms, which really differ in pathology and treatment. In some of them the sore mouth is the primary disease; in oth- ers it is secondary and symptomatic of some other affection. They range from a simple erythematous inflammation, which disap- pears of itself in a day or two, to that profound lesion in Avhich the tissues soften and break down as it progresses. AVe may divide these diseases into the following classes : Stom- atitis Simplex, Aphthae, Stomatitis Ulcerata, Gangrenous Stom- atitis. STOAIATITIS SIMPLEX. Simple sore mouth may be caused by cold, or by gastric irrita- tion, in some cases being the result of the two. The child first complains of its food burning or smarting the mouth, or if too young to make its sufferings known, it will be noticed that it cries Avhen it nurses. On examination the mouth Avill be found reddened and hot. 294 DISEASES OF CHILDREN. Frequently the inflammation is so slight that it will pass aAvay of itself in tAvo or three days; but in other cases, especially those which are dependent upon gastric disease, it Avill be remarkably persistent. Treatment.—In a large number of cases, Phytolacca is a very certain and speedy remedy, and I prefer its internal use to " mouth washes." As there is usually slight fever, the prescrip- tion will be—Py Tinct. Aconite gtt. ij. to gtt. v., Phytolacca gtt. v. to gtt. x., Avater 5iv.; a teaspoonful every hour. Occasionally the indications Avill point distinctly to Rhus, Avhen it may replace the Aconite. The local treatment is quite simple. An infusion of sage, sweetened with honey or loaf sugar, and borax added in the pro- portion of one drachm to four ounces ansAvers very well. An in- fusion of Hydrastis, of Coptis, or of Hamamelis, Avill also an- SAver a good purpose. Or, instead of these, a solution of chlorate of potash, gr. x. to water Si v., may be employed, In those cases which depend upon gastric irritation, ipecac may be addeel to internal remedies, or an infusion of compound pow- der of rhubarb anel potash may be given until it has a slight lax- ative effect. If the case is a persistent one, this may be folioAved by the subnitrate of bismuth, or liquor bismuth. In other cases benefit will result from the use of small doses of tincture of mu- riate of iron with glycerine. APHTHA. Aphthae occurs in three conditions of the system : as a simple sore mouth with exudation from gastric irritation, in cachectic conditions of the system, of Avhich it may be an evidence, and as an attendant upon severe forms of disease, being met with especially in their later stages AV.ien the vital poAver is nearly exhausted. In the first case the aphthous sore mouth yields readilv to treatment, anel is never regarded as presenting any danger. In the other two it is a very grave symptom, indicating a depression of the poAver to Vive, which renders the prognosis unfavorable. Symptoms.—The symptoms of aphthae are Avell marked. The child exhibits evidences of a sore mouth, and complains of ten- derness, smarting or burning, when eating; or, if nursing, it APHTH.E. 295 cries Avhen it takes the breast, and sometimes refuses it except when pressed by hunger. As it occurs in very young children, this Avill be the principal evidence of the seat of the disease. The chilel is fretful, uneasy, does not sleep Avell, has considerable fever, and cries persistently when it is given the breast, and fre- quently lets it go, bursting out into a prolonged and painful cry. Our attention being thus attracted to the mouth as the seat of a disease, Ave find the mucous membrane someAvhat swollen, red- dened, especially in patches, upon which there are numerous small Avhite points of exudation. The mouth is quite tender to the touch, and the child cries when it is examined. As the dis- ease progresses these points of exudation become more numerous, until finally the greater part of the buccal surface is thus cov- ered. When it occurs in cachectic children, or in Ioav forms of disease, the exudation occasionally extends to the tongue, covers the roof of the mouth, and sometimes involves the throat and nasal passages. The evidence of gastric disturbance will frequently be obscured by the sore mouth, but in almost every case there Avill be found some lesion of this kind. There is also a real febrile action, anel not, as some might think, simply a sympathetic disturbance of the circulation. Treatment.—In many cases the small dose of Aconite Avith Phytolacca will be a very much better treatment than the old plan. If there is no fever the Phytolacca may be given alone, gtt. v. to gtt. x. to Avater oiv.; a teaspoonful every one to three hours. If the face is full and purplish, and the tongue and mu- cous membrane of the mouth have a purplish-red hue, Baptisia should be substituted for the Phytolacca. If the tongue is red and covereel with a glutinous coating, sulphurous acid may be given in small doses, and also used as a Avash for the mouth. In- deed I think that in many cases it gives us the best local appli- cation. If there are erythematous spots of eruption on the sur- face, or small vesicles appear about the mouth, or there are start- in «-s in sleep, Avith contraction of the facial muscles, Rhus should be alternated with Phytolacca. If there has been a retrocession of an eruption, or Ave think there is an eruption under the skin, the patient Avill usually be dull and inclined to sleep, aud we give Belladonna. 296 DISEASES OF CHILDREN. These means I regard as of more importance than the local treatment, for with the removal of the internal disease the aph- thae disappears. The use of Aconite and small doses of sulphite of soda, are the most valuable of these in a majority of cases. As a local application, an infusion of Baptisia, a solution of chlorate of potash, or sulphite of soda, or sulphurous acid, may be employed. It may be applied with a soft cloth or sponge, care being taken not to rub or irritate the mouth. If the direc- tions are not explicitly given, we will find the mother or nurse - trying to rub the white spots off with the Avash, or, as she ex- presses it, she is trying to clean the mouth. You do not want the month cleaned, but the medicine applied. AVhen the aphthae is associated with a cachectic condition, the treatment should be decidedly tonic and restorative, and this should be aided by a nutritious diet and such hygienic means as will improve the general health. AVhen it can be taken, cod- liver oil ansAvers a very good purpose. Alternated with this Ave may give small doses of tincture of muriate of iron with glyce- rine. The hypophosphite of soda, tAvice a day, will be a good addition to the treatment in some cases; or in place of the iron and hypophosphite as named, the compound syrup of the hypo- phosphites may be used. The quinia inunction Avill prove beneficial in these cases. It should be applied with brisk friction, so as to stimulate the skin to absorption. The food should be principally animal; the lean of beef, mut- ton, game, milk, eggs, etc., will give a proper diet. Not tin- frequently changing the diet from farinaceous slops to well cooked meats, and a plentiful supply of milk and eggs, is better than any medication. No treatment can be laid doAvn for those cases of aphthae, which appear in the later stages of acute disease. It evidences the need of restorative medication, and the appropriation of food, but this has been clearly seen before the aphthae made its appear- ance. All that can be said is, let every effort be directed to placing the stomach in condition for the appropriation of some food ; and by the use of restoratives increase the poAver of diges- tion and assimilation, and by the use of that class called anti- septic, lessen the rapidity of decomposition. stomatitis. 297 STOAIATITIS ULCERATA. This is not a very common form of sore mouth with children, but is sometimes quite severe. It is difficult to determine the cause, and Avhy an ulcerative inflammation should be set up in a person seemingly otherwise healthy. AVe may surmise some depravation of the blood, but Ave can give no reason Avhy it should manifest itself in disease of the mucous membrane of the mouth, rather than other mucous membranes, or even other tissues. Symptoms.—AAre have in this case the same evidences that the mouth is sore, that have been named before The child manifests pain Avhen it nurses or when it eats. If old enough to express its sufferings, it complains of burning and heat in the mouth, anel a feeling of stiffness. Sometimes its voice will be changed, and it can ne>t articulate distinctly. On examination the mucous membrane will be found present- ing a uniform red blush, but patches will be maikeelly reddened, usually someAvhat discolored, dusky, livid, or blanched, and somewhat SAVollen. At a later stage of the disease, these swell- ings will have increased, and a vesicle having formed and rup- tured, a superficial ulcer Avill present. These ulcers will vary in size from the head of a pin to a elime, and in depth from a simple excoriation or removal of epithelium, to a dee}) excavation which passes through the mucous membrane. The ulcers are covered Avith a grayish or yelloAvish exudation, which when removed, leaves a red base. In some exceptional cases, the disease continues to increase for several days, and the ulcers are numerous and deep. There is free secretion of saliva of a sticky and tenacious character, Avhich, Avith the secretion from the ulcers, anel an increased mucous secretion, is removed with some difficulty, and keep the mouth in a very unpleasant condition. Treatment.—The constitutional treatment in this case is of more importance than the local means. True, in some mild cases, the use of chlorate of potash as a Avash, and internally, Avill be sufficient. AVhen the tongue is broad, pallid anel seems SAVollen, I like the action of sulphite of soda, in doses of two to five grains, every three hours. AVhere it is red am] covered with a glutinous nasty coat, sulphurous acid is the remedy. In other 298 diseases of children. cases the use of tincture of muriate of iron with glycerine may be alternated with it. The remedies named under the head of aphthae may find a place here, according to the indications, Phytolacca being especi- ally a good remedy. Following this, quinia with hydrastine may be given, or Avhen there are objections to the use of quinia by mouth, it may be employed by inunction. Occasionally, small doses of triturated Podophyllin can be used with advantage, but it must never be carried beyond a slight laxative effect. The cases in Avhich I Avould deem it necessary, Avould be those where the tongue avus covered uniformly with a yellowish coat, some tumidity of boAvels, with papescent and clay-colored stools. The local applications in this form of sore mouth are, an infu- sion of the baptisia, sulphurous acid, or sulphite of soda. As already named, the chlorate of potash ansAvers Avell in the milel cases, but can not be depended upon in those more severe. An infusion of Hamamelis is a good mouth wash in some cases. And in very stubborn ones a decoction of equal parts of Rumex crispus, Alnus serrulata, and Quercus rubra. Occasionally one or two ulcers will be very persistent, and not yield to the ordinary treatment. Such may be lightly touched with the stick nitrate of silver. GANGRENOUS STOMATITIS-CANCRUM ORIS. Cancrum oris may folloAV stomatitis ulcerata, but in the ma- jority of cases is a distinct disease. There seems to be a depra- vation of the fluids, and an impairment of the vitality of the solids. It bears a very close relationship to cynanche maligna, and presents many of the same symptoms. Symptoms.—Gangrenous stomatitis commences with a hard- ness and swelling of the cheek and lips; when this appears exter- nally, it presents a blanched glossy appearance. ,On examining the mouth Ave find but little tenderness, the part SAvolleu being but slightly redder than usual, more frequently duskv, livid, or blanched, and having in its center an ash-colored eschar. The tongue is pale and semieAvhat coated, the stomach and bowels deranged, Avith marked exhaustion and cachexia, with languor 7 O and restlessness. STOMATITIS. 299 The eschar soon spreads, sometimes extending to the lips and gums, and is attended Avith a copious discharge of saliva, Avhich soon becomes fetid ; the secretions of the mouth and the breath are quite offensive. As the ulcer progresses it extends both in depth and circumference Passing through the mucous mem- brane, it involves the cellular tissue, and frequently dissects the parts for some distance beyond the circle e)f ulceration. Thus the ulcer is larger, and, in every respect worse, deeper in between the tissues, than it sIioavs in the mouth. Still progressing, it destroys part after part, until near the sur- face. Noav a small vesicle or pale ashy-colored spot is formed upon the skin, which soon becomes livid and sloughs. The ulceration iioav spreads rapidly, destroying the muscles, integu- ment, and bones, until death terminates the child's sufferings. When the ulceration has progressed in this Avay, recovery oc- casionally takes place, leaving the child fearfully deformed. In olden times, when mercury Avas constantly used for all ailments, such cases of stomatitis Avere not unfrequent. As mercury vasthe direct cause, these cases received the name of mercurial stomatitis. In some of these eases of mercurial sore mouth the gums will be swollen, spongy and pale, sometimes bleeeling upon slight pressure A nasty Avhito sordes accumulates about the teeth- which are loosened, anel presently Ave observe a white eschar forming on the edge of the gums, which separating leaves a foul ulcer. The child suffers constantly, can take but little food, and the fetor is so great that it is perceptible in all parts of the room. I have seen just such results from the Homoeopathic use of mercury. DiagnOjI.j.—This disease will usually be readily determined. The child complains of sore mouth, and presents a markedly cachectic appearance The breath is fetid, the secretions un- pleasant, the mucous membranes pallid or livid. Then the cir- cumscribed SAvelling and hardness as described with the com- mencing ulceration, Avill be sufficient. Treatment.—The treatment of this case will be varied to meet the indications, yet Ave obtain the best results from the use of chlorate of potash and chlorine Avater, sulphurous acid, sul- phite of se>da, Phytolacca or Baptisia. In some cases quinine (in malarial regions) is administered internally, but in many the inunction of quinine once a day Avill ansAver the best purpose. 300 DISEASES OF CHILDREN. Especial attention must be given to the food of the child, which, of course, is to be fluid. Hot milk with a small portion of salt, is a very common and good food ; beef-tea, if there is a feeble cir- culation anel muscular feebleness; rice nicely prepared with milk, tapioca, farina,etc., must be selecteel as occasion requires. If there is some febrile action, small doses of Acemite can be used Avith benefit. Occasionally the bowels are sluggish and the patient suffers from retention of feces ; in place of giving a cathartic, the boAvels may be moved by a stimulant enema. The points of ulceration I touch Avith nitric acid, being care- ful to reach all the parts involved. I use the strong acid with a piece of pine Avood, so shaped as te> be most easily applied. There is no trouble or danger in the use of this, if the precau- tion is used of holding it for a moment until anv free acid has disappeared. The application should be thorough, both for the purpose of arresting the spread of ulceration at once, and to pre\rent the pain of frequent applications. Sometimes one will be sufficient, at other times it will haATe to be repeated for three or four days. In addition to this cauterization, the mouth should be Avashed with an infusion of Baptisia, or of the Rumex, Alnus, and Quercus, heretofore named. These Avill sometimes be found better than the chlorate of potash, so commonly used. SORE THROAT. AVe have no technical term that will answer to designate the different lesions that are grouped together under the name of sore throat. The situation of the disease varies in different cases. In some the inflammation is of the fauces, tonsils, and base of the tongue, in others it is of the pharynx proper, and in others still, it involves the posterior nares, the velum, and to some ex- tent, the larynx. The character of the disease also varies in different cases. In some, it seems scarcely more than an irrita- tion. In others, it is an acute erythmatous inflammation. In others, the deeper tissues are involved, and there is considerable swelling. And in still others, the inflammation progresses to change of structure and ulceration. Causes.—The most common cause of sore throat is cold, though Ave can give no reason why it should so frequently affect the throat. In some cases, it seems to be associated Avith gastro- intestinr.l irritation. SORE THROAT. 301 Symptoms.—AVe determine the existence of sore throat in the nursing child, by the uneasiness and evident pain as it nurses and swallows. Sometimes it will refuse the breast on this account. Usually the child is more or less feverish, is irritable, sleeps poorly, and Avants to drink frequently, though to swallow the Avater occasions pain. The throat becomes dry, and is the principal reason for the craving for drink. On examination Ave find the throat presents evidences of in- flammation, in its redness, dryness, anel heat. It is not always that Ave can make a satisfactory examination of the throat, and Ave Avill have to be satisfied from the redness observed about the base of the tongue and fauces. Treatment.—The simple sore throat of childhood yields readily to simple treatment. The patient is placed upon the use of Aconite, witli Phytolacca, in the usual doses, which are con- tinued every hour, until all evidence of the disease has disap- peared. The child has a hot mustard foot-bath once or twice daily, and occasionally a general bath. The local application to the throat externally is, where one is necessary, a flannel cloth wrung out of colel vinegar, Avith a dry one over it. If there is some hoarseness the Stillingia liniment is advisable. The young chilel can not use a gargle, indeed, it is almost use- less until they reach the age often or twelve years. In its stead, if anything is necessary order the remedy in this form: Py PoAvdered Gum Arabic, Loaf Sugar, Chlorate of Potash, aa. make powders of five grains, and direct that they be put upon the child's tongue dry, and dissolved by the secretions of the mouth, sloAvly SAvalloAved. These may be repeated as often as every hour, and will generally ansAver the purpose well. In older persons, a gargle of chlorate of potash, of sulphite of soda, of Baptisia, or of Hydrastis, may be used Avith success. AVhen the disease is severe, and requires more prompt relief, I direct that an inhalation of the vapor of Avater, or Avater and vinegar, be used. If no apparatus for inhalation is convenient, Ave may employ the means found in eA^erv house; sometimes sprinkling the fluid on a heated shovel or iron will answer, the chihl being placed in such position that the vapor may be inhalevl. A better plan is to heat the fluid in a tin or other vessel, anel place it near the child, throAving a light blanket or shawl over it and the child's head ; a hot iron is gradually put in the fluid, 302 DISEASES OF CHILDREN. raising the necessary quantity of steam. Occasionally the inhala- tion may be medicated Avith advantage ; an infusion of Baptisia, of Hamamelis, or of tansy from the garden, Avill ansAver a good purpose CYNANCHE MALIGNA. Malignant sore throat usually prevails as an endemic, some- times as an epidemic, and occurs most frequently in the winter and spring. The cause is someAvhat obscure. For some reason the tissues of the throat are weakened, and a Ioav grade of inflammation is set up. There is, doubtless, blood poisoning, as Ave observe in analogous cases. Pathology.—There is a Ioav grade of inflammation, of which malignant sore throat and epidemic dysentery are examples, that most frequently has its origin in some local miasm, animal or vegetable, which affects the atmosphere of limited portions of country. All the symptoms point te> a poisoning of the blood, and depravation of this fluid, and consequently of the secretions, and of nutrition, as one of the principal elements of the disease. The local disease, however severe, would not occasion uneasiness, if the general health was good, but with depravation of the fluids and solids, and the attendant prostration, the disease becomes one of the severest Ave are called to treat. Symptoms.—For tAvo or three days, sometimes for a week, it is noticed that the chilel looks pallid, its skin Avaxy or pasty, and that there is a Avant of expression in the countenance and of eneroy in play. The breath is also bad, the tongue broad and pale and someAvhat loaded. The child's appetite is variable, it rejects its breakfast, but eats dinner or supper. Frequently it refuses its usual food, and wants sweets and fruit. For a day or tAvo, in some cases, it complains some of its throat. In some cases the disease is fully announced by a chill, of longer or shorter duration. But in others there is such a gradual increase in the symptoms that it is difficult to separate the form- ing stage from the fully developed disease. AVhen the physician is called he finds e\Tidences of a general and a severe local disease. The pulse is soft, easily compressed, and increased in frequency from ten to thirty beats per minute. The extremities are kept warm with difficulty, the skin is pallid cynanche maligna. 303 or salloAAr, and presents a peculiar Avaxy appearance, looking many times as if it Avas oedematous, ami would pit on pressure. The face is pallid and expressionless, with a dark line under the eyes, which also are dull, with dilated pupils. The boAvels are irregular, the feces clay-colored and papescent; the urine free, pale, and of Ioav specific gravity. There is no appetite- indeed, from the condition of the mouth and throat, there is disgust fin- food. On examining the mouth and throat Ave find the mucous mem- branes pallid, the tongue broad, pitting where it comes in con- tact with the teeth, and covered Avith a pasty, white coat. The mucous membrane of the throat is SAvolleu anel discolored ; in some cases it is livid, in others of a dusky-red, and in some few it presents a peculiar blanched appearance. The tissue seems relaxed and flaccid, ami the circulation sluggish. In a couple of days small points of ulceration will be seen, sometimes superficial, at others with a tendency to extenel in depth. These ulcers increase in size more or less rapidly, accord- ing to the severity of the disease, and the throat Avill present a remarkably ragged and foul appearance. In very severe cases the ulcers pass through the mucous membrane and invade the cellular tissue, so that in fatal cases the structures are destroyed to a greater extent than Ave Avould deem compatible Avith life, for some hours before death ensues. A distinctive symptom of malignant sore throat is the change in the tone of the voice; it is not so much hoarse as holloAV and sepulchral—as a musician would say, " it has lost its timbre." Diagnosis.—This disease is readily recognized by the fetid breath, the abundant secretion from the throat and mouth, and by the peculiar relaxed condition of the structures. Adel to this the general cachexia, which is peculiar to this, and, to some ex- tent, to cancrum oris, and Ave have a grouping of symptoms that can not be mistaken. Prognosis.—Though the disease is a very unpleasant one, anel attended with such depravation of the fluids anel solids, the prognosis is not unfavorable. A large majority of cases will recover, probably as much as ninety or ninety-five per cent. Treatment.-—T:ie treatment of cynanche maligna Avill be both constitutional and local. AVe Avant to antagonize the septic 304 diseases of children. influence, improve the circulation of the blood, increase the tone of the system, and place the stomach in conelition to receive and appropriate fe>od, anel re-establish see-retion. Aconite'*and Belladonna may be given in small doses, to im- prove the circulation, or if the cervical glands are enlargeel Phy- tolacca takes the place of the BelJadonna. Under their influence we finel the pulse becoming stronger anel more full, the capillary circulation better, and the temperature of the body more uniform. Of the antiseptics I prefer sulphite of senla in the majority of cases, giving it in the usual doses, every three hours. In some cases chlorate of potash may be used instead, or alternated Avith the sulphite Triturated Avith gum arabic and sugar, as named for diphtheria, will probably be the best form of administration. The Baptisia in infusion is an excellent antiseptic, and may be associated with either of them. In addition to this, I prescribe quinine in stimulant doses, sometimes alone, at others in combination with Hydrastine. The dose will be about one-half grain, three or four times a day. Tincture of muriate of iron can also be used Avith advantage in some cases. It may be specially named as an important remedy in those cases Avhich manifest an erysipelatous tendency. The local means will vary in different cases. In the milder ones a decoction of Baptisia, used as a gargle, will be sufficient. In others Ave may alternate this with a gargle of chlorate of potash, anel in others the sulphite of soda will ansAver a gooel purpose. In those cases Avhere the tissues are relaxed, anel the ulceration progressing rapidly, the sulphurous acid Avill be the most poAverful, as Avell as the most certain local remedy Ave can use. AVe Avould make the solution of the strength of one ounce of the acid to three ounces of water. AVhen it is used with a pencil or probang it may be applied of full strength. But gargles can only be used with children Avho have attained to six or ten years, and in younger children we will have to de- pend upon other means. Of course, the sulphite of soda, chlorate of potash, and Baptisia, can be so employed as to get their topical action, as they are taken. I do not like the use of the probang, or the swab, to make local applications to the throat of children. Instead of this I use inhalation, preferring the spray apparatus, either air or steam, to any other apparatus. But it does not re- quire an instrument, for, as Ave have already sIioavii, an inhala- tion can be given -with nothing but a vessel to hold the fluid and chronic sore throat. 305 a heated irem to raise a vapen-. The vapor of vinegar and Avater answers an excellent purpose, as does an infusion of tansy, or of Baptisia. In using the spray apparatus, I use the same remedies named for gargles. The external application in this, as in many other diseases of the throat, is a flannel wrung out of cold vinegar, Avith a dry flanue'l ewer it. AVe call it the vinegar pack, but a cold Avater pack to the throat will ansAver the purpose. CHRONIC SORE THROAT. AVe are not accustomed to think of chronic disease in child- hood, and yet Ave have many that are as strictly so as any disease of the adult. Among these is a chronic sore throat, Avhich is very troublesome, and, like other chronic diseases, manifests no tendency to recovery. Causes.—It is sometimes difficult to determine the cause of this elisease. In all cases, I believe, it Avill be found associateel with a scrofulous cachexia, or at least a tendency te) disease e>f mucous structures. With such tendency as this, all that is neces- sary is that from colel or gastric irritation a .simple inflammation of the throat be set up. This continues on until it produces the conelition Ave are considering. Pathology.—As just named, there is almost invariably a cachectic condition of the system, a tendency to disease of this character, Avhich Avill manifest itself in different tissues, as they may suffer from some acute irritation or inflammation. Such children rarely live to adult years, anel furnish subjects for the various forms of scrofula, hip-joint disease, Avhite swellings, and finally phthisis. True this predisposition may be removed by a judicious and long continued course of training, but it is rarely adopted. Symptoms.—The attention Avill be draAvn to the throat as the seat of disease, by continually recurring attacks of slight sore throat. Sometimes it will seem to involve the respiratory organs more; there will be a hacking cough, frequent endeavors to clear the throat, and slight difficulty in respiration. AVith such at- tacks the child is fretful, anel has slight fever. 20 306 DISEASES OF CHILDREN. AVe notice it at all ages, from three months old to the close of life, and it presents somewhat similar symptoms. The evidences of general cachexia Avill vary in different cases, sometimes being marked, while at others the child seems quite healthy. Upon examination of the throat AATe finel the mucous membrane relaxed and thickened, the mucous follicles enlarged, and the circulation sluggish. There is also change in the color of the parts; they have become a dirty reel, dusky, livid, but more fre- quently a pallid red. The tonsils are frequently enlarged, and the mucous follicles about the base of the tongue are also en- larged, and keep the part constantly covered Avith their secretion. In very bad cases the throat presents a peculiar appearance; the pillars of the fauces seem thickened, as is the velum and uvula, anel with the enlarged tonsils, present a misshapen ap- pearance. The voice in this case has changed, becoming fluffy or holloAV, and lacks distinctness in articulation. Treatment.—AVhen the child presents evidence of a scrofu- lous cachexia, we proceed to treat that as named for scrofula. Usually it is not so marked, and our treatment Avill be a tonic and restorative general treatment. The tonic for a child, as I have had occasion to name several times, is tincture of muriate of iron, with cod-liver oil if the child Avill take it. A\Te make the usual prescription : Py Tincture of Muriate of Iron 5j-, Glycerine Si v., a teaspoonful three times a day. If the appetite is poor, or there is an infantile dyspepsia, a small portion of tincture of Nux Vomica may be added to it. A very good means in this case is the use of Collinsonia. For a child tAvo years old, I would prescribe: Py Fluid Extract of Collinsonia 5-ss, Simple Syrup Siv., a half teaspoonful every tour hours. If the child is old enough to gargle the throat, I direct an infusion of Hamamelis, or the fluid extract, in the pro- portion of one-half ounce to six ounces of water. The vinegar pack to the throat, with the cold sponging in the morning, is an important part of the treatment. As is the case with all other chronic diseases of the throat anel larynx, the patient seems to be continually taking cold, and this prevents that continuous amendment necessary to complete recovery. The use of the pack, even of cold Avater, with the colel sponging of the neck and shoulders, is the most efficient means to prevent this. gastrodynia. 30 i GASTRODYNIA. I use the term gastrodynia to express the condition of pain in the stomach, Avhether the pain is the result of irritation of the gastric nerves, from cold, from irritative ingesta, or from spas- modic contraction of the muscular coat. In slight degree it is of very frequent occurrence, and is quite often seen in a severe form. AVith some children it is of daily recurrence, and is usually called colic by mothers and nurses. It not only causes much suffering to the child, but is source of very great annoy- ance to the parents; and when the mother is in feeble health, it becomes a serious matter, and if possible must be removed. Causes.—The most common cause of pain in the stomach is indigestion. The chilel nurses Avell, and frequently thrives, but some portion of the food unelergoes decomposition and proves irritant, or generates gas which unduly distends the stomach. In some of these cases there seems to be a peculiarly irritable condi- tion of the gastric nerves, so that a very slight cause is sufficient to proeluce pain. In other cases it results from cold, and in these there is fever; and in others there is a real spasmodic action, or cramp of the stomach. Symptoms.—The child exhibits evidences of pain in its coun- tenance, is uneasy, and Avill not remain in one position, and has violent paroxysms of crying. In some cases the body is drawn up, anel the loAver extremities are flexed upon the abdomen. Occasionally there are eructations anel some of the food is thrown up, showing imperfect digestion ; but at other times the milk will be curded anel SAveet, showing healthy digestion. In the majority of cases the pain is paroxysmal, lasting for five or ten minutes, during Avhich the child seems to suffer severely, and cries violently; it gradually abates until there is comparative ease, and as Ave are about to congratulate ourselves that the pain has wholly passed away another paroxysm comes on suddenly. Thus it may continue for an hour or tAvo, or for a considerable portion of a day. Treatment.—In many cases Ave find one or two drops of tincture Nux to a half glass of Avater, given in half teaspoonful doses, every fifteen minutes to one hour, will give speedy relief. 308 diseases of children. If there is irritation of the boAvels, also with griping pain, Tinct. Colocynth gtt. j. to gtt. ij. te) water oh'-, a teaspoonful every half- hour te> hour will give speedy relief. In some cases Aconite may be used Avith both of these, and aids in relieving the pain- Dioscorea in infusion, the tincture gtt. v. to gtt. x., to Avater 5iv., is a good remedy. Apis ansAvers a good purpose Avhen the pain in the stomach is asse>ciated with an eruption like " heat," and Belladonna, if such an eruption has disappeared from the surface. The old remedies, after the folloAving formula, may sometimes be given: Py Tincture of Lobelia oj., Compound Tincture of Lav- ender oi'jv Simple Syrup 5jss. ; the dose will be from one-fourth to one teaspoonful, anel may be repeated as often as necessary. Another excellent preparation is: Py Chloroform gtt. xx., Glycerine Sij., in doses of one-fourth to one teaspoonful, as often as required. AVhen these attacks are of frequent occurrence in nursing children Ave may suspect a Avrong in the mother's diet or diges- tion, and this being looked after, Ave will sometimes find that our little patient has more comfort. In other cases the pain is a symptenn of infantile dyspepsia, ami lime-Avater, phosphate of soda, or some of the simpler tonics, Avill give permanent relief. The best local application, as a general rule, Avill be a hot dry flannel applied over the stomach and abdomen. Sometimes the use of the hot flannel to the spine Avill give speedier relief than when used over the stomach. In children of one year and older a mustard plaster may be used. GASTRIC IRRITATION. We are called to prescribe for cases in Avhich there is marked irritation of the stomach. It occurs as a complication of many acute diseases, and sometimes alone, there being no other disease present. In the first case it increases the severity of the primary disease, prevents the absorption of remedies, and the takino- and digesting of food. It thus becomes, when severe, an unfavorable complication. Causes.—AVe can not determine, in many cases, any cause for this irritation. In some it depends upon imperfect digestion of fi)od, in others from cold and arrested secretion. In acute dis- ease it is doubtless owing in part to decomposition of food, taken before the disease Avas fairly announced. gastric irritation. 309 Symptoms.—Prominent among the symptoms is the occasional nausea, retching, and effort to vomit. The child is thirsty, and desires drink frequently, but Avhen any quantity is taken it is ejected by vomiting. If nursing, it Avants the breast frequently, and after nursing it throAvs up its milk. When the child is Aveaned, it will generally reject all food. If medicine is given, at least many kinds, it Avill be thrown up after a time. Thus, in the treatment of acute disease, Ave may- be giving the sedatives, or any remedies, every hour; the child takes three or four doses, and then there is sickness of the stomach, and the whole is ejected. Thus, many times, the treat- ment Avill go on day after day Avithout any appreciable influence upon the disease, none of the medicine having gained entrance into the circulation. In this condition of irritation osmose is from the blood-vessels to the stomach, and of course there is no absorption either of food or of medicine. Irritation of the stomach, Avithout other disease may continue fe>r several days, or in slight degree for twe> or three Aveeks. Necessarily there is sympathetic disturbance of the nervous system, and of other functions, and eligestion being arrested the chilel is much prostrated. There is an irritation of the stomach, arising from disease of the brain, that is of very serious import. This case is diagnosed by the contracted and pinched appearance of the ceuintenance, the dullness of the eyes, and the increased frequency and hard- ness of the pulse (there are some exceptional cases in Avhich the pulse is small anel Aveak). The skin is dry, sometimes husky, the temperature of the trunk slightly increaseel, but the extremi- ties are cold. If the tongue is examined in irritation of the stomach, it Avill sometimes be found reddened, contracted, and pointed, in others pale and atonic ; in the one there is irritation with determination of blood, in the other atony. If coated, it will be with a white fur, confined to the center. Treatment.—AVhen there is febrile reaction, or increase of temperature, I direct cold applications over the epigastrium. In the opposite cases, a sinapism or a spice plaster may be used. In all cases much benefit will follow the use of the hot foot bath, which, if the extremities are inclined to be cold, may be rendered stimulant by the addition of mustard or capsicum. 310 diseases of children. Internally, if the tongue is elongated anel red, Ave may admin- ister small doses of Aconite and Ipecac, say : ly Tinct. Aconite gtt. j. to gtt. ij., Tinct. Ipecac gtt. v. water 5iv., a half teaspoon- ful every hour. If the pulse is sharp and the patient has frontal headache, the remedies will be Aconite and Rhus. In the second case, Avhen there is evidence of atony, the prescription will be: Ty Tinct. Nux gtt. j. to gtt. ij. Avater 5iv., a teaspoonful every half hour. Occasionally an infusion of our old fashioned compound powder of rhubarb given in small doses Avill give relief. In place of this, and better adapted to severe cases, is an infu- sion of the bark of the peach-tree. AVe ta£e the young and green limbs of the present year's groAvth, scrape the bark off, cover it Avith boiling Avater, and Avhen cold it is ready for use. AVe giA'e it at first in doses of one-fourth to one-half teaspoonful every few minutes until the irritation has partially subsided ; afterAvards in teaspoonful doses for two or three hours. Occasionally Ave Avill obtain benefit from the preparations of bismuth; either the subnitrate, carbonate, or liquor bismuth may be used. The first I generally prescribe Avith mint Avater, in doses of from one to three grains. AVhen the irritation is A'ery persistent, the boAvels being consti- pated, an enema of a Aveak salt Avater to move the benvels, wiii aid in giving relief. If the temperature is high the injection may be cold, if the patient is exhausted the injection should be: hot. In these severe cases Ave are very careful in administering remedies and giving food after the irritation seems to have been subdued. GASTRITIS. Acute inflammation of the stomach is rarely met with in the child, and only, as I believe, from the administration of irritant medicines. Subacute inflammation, hoAvever, is met with quite frequently, and is sometimes very persistent. Causes.—The causes of inflammation of the stomach are tAvo- folel. It may be produced by the ordinary causes of inflamma- tion in other organs, as from cold, arrested secretion, etc. It is also the result of irritant ingesta, or of such decomposition of food as gives rise to irritant products, or to irritant secretions. gastritis. 311 Symptoms.—Subacute gastritis may occur as an idiopathic affection, or as a complication of some other elisease. In the first case it is announced by nausea, retching, and vomiting, following a short forming stage, in which for a feAV hours the chilel has been restless anel uneasy, not caring for food, but Avanting to drink freely. Occasionally there is a pretty well-marked chill lasting for an hour or two. The retching and vomiting are not constant, but come on at longer or shorter intervals, are quite violent and attended with much straining. AVhen the stomach is thus relieved for the time being, the chilel seems to lie easily, and sometimes falls into a short sleep. Presently the thirst increases, it wants drink con- tinually, and having taken but a small amount, vomiting again commences. There is always more or less fever. Usually it is paroxysmal, following the course of the vomiting, coming up after this has stopped anel gradually increasing until the nausea and vomiting commence. After the nausea and vomiting have continued to relaxation, the fever passes off, to re-appear again, as^ before named. In some cases the nausea and retching simply increase the irritation of the nervous system and the circulation, and there is no abatement of the febrile action. In some cases the irritation of the nervous system is very great, and manifests itself in uneasiness and restlessness, crying and other evidences of suffering. In a few cases the irritation is of such character as to produce convulsions, which are usually very severe and intractable. Should the gastric irritation not be arrested, it will result in one of three ways. In nervous irritation, occasionally convul- sions, and finally coma, gradually increasing until it proves fatal. In irritation of the intestinal canal, and diarrhoea, which, running the usual course, terminates in the same manner as muco-enteritis. In an irritative fever, which rapidly assumes typhoid symptoms, and proves one of the severest diseases we are called to treat. Treatment.—The treatment of an inflammation of the stomach is quite simple, and usually very successful. The first object is to so modify the irritation as to stop nausea and vomit- ing, for these perpetuate if they do not increase the irritation ; afterward we have time for the removal of the inflammation. The patient has a general bath if febrile reaction is high, fob 312 DISEASES OF CHILDREN. loAved by a hot-mustard foot-bath, continued for twenty-five to thirty minutes. In some cases a general hot bath, using salt in the water, will prove beneficial; if this be used, the applications te> the epigastrium should also be hot. In the majority of cases, I prefer cloths wrung out of cold ^ater, over the stomach. In- stead of this, a sinapism made of three parts of flour to one of .mustard, may be used. Internally I Avould prescribe an infusion of peach-tree bark, in doses of one-fourth to one-half teaspoonful, frequently repeated. The infusion is made of the bark of the limbs of the present season's growth. In place of this, bismuth with mint Avater may be emplewed, as named for irritation of the stomach. In some cases, those especially in which the inflammation is not high, Ave may use the compound powder of rhubarb in infusion. To modify the febrile action small doses of Aconite are em- ployed ; five drops to four ounces of Avater ; a teaspoonful every half hour or hour will be the proper quantity. If there is much irritation of the nervous system Ave may give the Gelseminum, in doses of from one to three drops, with the sedative. AVe find that these remedies not only ansAver their specific purpose, but they also have a beneficial influence in arresting gastric irritation. In some cases we find the boAvels inactive, and occasionally the gastric disease is increaseel by accumulations in the intestinal canal. As it is clearly out of place to give cathartics by mouth, we must depend upon enemas. An enema of salt watar Avill sometimes exert a marked influence in checking nausea and vomiting; not so much in gastritis, of course, as in simple irrita- tion of the stomach, yet its influence in this respect is beneficial. Simple enemata are used when the object is to empty the loAver bowels, but when the small intestine is to be reached, the enema should be of compound poAvder of Jalap, or of castor oil, in Avarm Avater. INFANTILE DYSPEPSIA. To many persons the name infantile dyspepsia Avill sound singular, as they have been accustomed to think of dyspepsia as associated with a long-abused and v/orn-out stomach. Yet dys- pepsia is a very common complaint with the chilel, almost as fre- quent as in the adult, though not so persistent. There are several causes of infantile dyspepsia, anel Ave will obtain a better knoAvledge of the disease anel of its therapeutics, INFANTILE DYSPEPSIA. 313 if Ave study these. They have reference to the quality anel quantity of the food, to the secretion of gastric juice, to the muscular action of the stomach, and to the condition of the upper intestinal canal. We find this disease most commonly in children who have other food than the mother's milk. Here the trouble is in the difficulty Avith which the food is digested, anel the imperfection of this process, in which some portions undergo decomposition. This may be corrected in some cases, to a limited extent, by changing the food, by giving it in a less concentrated form, and in such manner that the secretion of saliva may be increased. Thus in a case Avhere the child was being fed on cow's milk, simply diluting the milk Avith one-fourth Avater has proved suc- cessful. Or, when it was fed with a spoon, or from a cup, the use of the bottle, so as to call for the act of sucking, Avould cause an increased flow of salh-a, and the little patient Avould be greatly benefited. A very common cause of infantile dyspepsia is over-feeding. This is the most common cause in nursing children, and depends not only upon the taking of too large a quantity at a time, but upon its too frequent nursing. In the one case the stomach is overdistended, anel overAVorked, and gradually it loses its poAver of digestion, and evidences of dyspepsia are manifested. In the other case the stomach is alloAvcd no repose, in which to regain its lost poAvers, or for its nutrition. The result is that its func- tion becomes gradually impaired. In another class of cases the dyspepsia is dependent upon a bad blood, from the many causes heretofore named for this de- terioration. The child is cachectic, lacks poAver in every direc- tion, and this, as well as other functions, are impaired. Dyspepsia is not ahvays a gastric lesion. The small intestines have as much to do witli the digestion of fooel as the stomach, and a lesion here gives rise to dyspepsia. Generally this, so far as Ave can see, is a simple atony, at other times it is an irritation. The atony is not only of the small intestine, but also of the liver, the pancreas, anel indeed of all associated parts. In such cases the circulation of blood and the innervation are deficient; there is a Avant of normal stimulus. So in cases of irritation, the associated organs are involved, to a greater or less extent, and there is too much blooel and innervation to these parts. There are cases in which a failure of poAver in the muscular 314 DISEASES OF CHILDREN. coat of the stomach is a cause of dyspepsia in infants, as well as adults. Others in which there is a elefect in the secretion of gastric juice, either in quantity "or quality. These in the child are principally of an atonic character, anel hence there Avill not be so much difficulty in the treatment as in the disease of the adult. Symptoms.—The symptoms of dyspepsia in the child vary greatly ; in some cases being well marked, in others obscure Usually the chilel is uneasy after taking its food, and is fre- quently troubled with colic. Vomiting of the fi>od is of common occurrence, and it the matters ejecteel are examined, the food will be found acid, smelling sour anel sickly, or undergoing incipient decomposition. These changes in the matter ejected arc pathog- nomonic; for in the vomiting which folIoAvs mere repletion, in which case the overloaded stomach takes this easy mode of re- lieving itself, the fooel is SAveet, the milk Avell curded, presenting evidences of a healthy condition of digestion. AVith this digestive lesion we notice that the child becomes pale, the tissues soft and flabby, the circulation feeble and the extremities cold. There is also, in most cases, very marked irri- tation of the nervous system, the child being restless, irritable, and fretful, and at night tosses about, aAvakes frequently, ami wants to drink. In some cases there is the same desire fen* food, even a ravenous appetite at times. In other cases the appetite slowly fails, and the child cries neither for food nor for the breast. AVhen this form continues for any considerable time, the child becomes anaemic and much debilitated. The simplest division of these cases is into the irritative and atonic. In the first case the evidence of gastric irritation isprettv well marked. There is the red tongue, the irritability of the nervous system, the pinched face, and bright eyes, the harsh skin and the greenish acrid discharges from the bowels. In the atonic form of dyspepsia, the tongue pale, a whitish pasty fur accumulates at its base, the breath has a sickly odor, the child is feeble and languid, and likes to remain in one position, the face is pallid, the eyes dull, the face expressionless, the skin soft, relaxed, and cool, the pulse soft anel feeble, and the discharges from the boAvels light-colored. Diagnosis—The diagnosis Avill be made in part by the symp- toms aboATe-named, Avhich point to the stomach as the seat of a INFANTILE DYSPEPSIA. 315 lesion, and in part by exclusion. The difference in the diagnosis betAveen the adult and the child is, that the first points out the location of the unpleasant sensations, Avhile in the second Ave have to determine this by careful observation. By making the ex- amination thorough Ave are enabled to exclude one organ after another until the evidence of the gastric lesion becomes positive. Prognosis.—The prognosis is not ahvays favorable. It will depend much upon the kind of food the child is taking; if nurs- ing, it is favorable; if fed on cow's milk or other food, it is un- favorable. It is generally grave in proportion to the change in the matters vomiteel ; if they are but little changed, or seem to be undergoing the process of digestion in a proper manner, Ave conclude that the lesion of the stomach is simple in its nature. But if they are undergoing decomposition, anel have an unpleas- ant odor, the evidence of serious lesion is pretty strong. Treatment.—The first thing that engages the attention of the physician is the food of the chilel, for as Ave have seen above, the lesion is frequently dependent upon a wrong in this. If the child is being raised on coav's milk, or other artificial food, Ave Avill see that this is the best of the kind, and properly prepared anel given. AVhen the dyspepsia is persistent Ave will have to take into consideration the propriety of changing it. Liebig's fooel Avill answer a good purpose in many of such cases, when the chilel is being fed upem milk. The elirections, heretofore given under the head of food for the child, may be studied with advantage. AVhen the chilel is nursing Ave Avill inquire as to the mother's diet, for ne>t unfrcquently indiscretions upon her part Avill have caused, and may perpetuate, the disease. Usually it is the use of vegetables and fruits in too large quantity that has first oc- casioned it. In some cases the dyspeptic lesion of the child de- pends upon a similar gastric lesion upon the part of the mother, anel it is her imperfect digestion Avhich deranges its stomach. In case of indiscretions in diet, Ave Avill represent the import- ane-e of care in this regard ; and Avhen this is not so manifest it will be well to change the mother's food until Ave have discovered Avhat Avas giving rise to the trouble. AVhen the mother suffers from dyspeptic symptoms, or has imperfect or feeble digestion, it will be proper to put her upon a course of treatment that will restore the functions of the stomach. 316 DISEASES OF CHILDREN. A very marked case of this kind came under my care in the earlier part of my practice. A lady had given birth to five children, of which three had died of infantile dyspepsia. One Avas saved by weaning, and the fifth, at the age of three months, was suffering severely. I treated the mother for chronic gastritis, by the use of the irritating plaster over the stomach, anel an in- fusion of hydrastis taken internally, anel as the irritation disap- peared added iron anel phosphorus. As the gastric symptoms of the mother disappeared and her health improved, the child became better, and in a few Aveeks Avas doing as Avell as other children. In some cases Ave Avill have to take into consideration the propriety of Aveaning the child, as it becomes evielent that the disease can not be controlled otherAvise. In some, feeding the chilel with cow's milk is attended Avith benefit, though in others the child rapidly fails after it is put upon it. Liebig's food, when the child Avill take it, usually does well. AVhen artificial food disagrees with the child it increases the pains in the bowels, and is either vomited or is carried off by a diarrhoea. In all such cases the chances of saATing the child is much better if a suitable Avet-nurse can be obtained, and this should be clearly stated to the parents at as early a period as possible. In some cases the employment of restoratives and tonics Avith the mother, and the use of well-cooked animal food, will be the best treatment for the child. Tincture of muriate of iron and glycerine, with the addition of tincture of Nux Vomica, if there is atony of the stomach, answers very well. Hydrastis, Avith same preparation of iron, is a good bitter and stomachic. The hypophosphites have proven serviceable in my practice, either singly or in the form of compound syrup of the hypophosphites. In some of the more simple forms of infantile dyspepsia Ave Avill find the administration of phosphate of soda in small doses, three or four times a day, either alone or with the food, Avill ansAver an excellent purpose (about ten grains daily for a child three to six months old). Common salt will alse> exert a marked beneficial effect Avith nursing children, in some of these cases. Where the dyspepsia is of the irritative form, I prescribe an infusion of peach bark, as heretofore named, and some preparation of bismuth. The subnitrate or subcarbonate in powder, or the liquor bismuth, in small doses. With these, and proper hygienic means, the irritation Avill have so abated in one or two Aveeks, the child can be put upon the use of Collinsonia and tincture of colic. 317 muriate of iron. Where there is evidently accumulations in the email intestine, an infusion of the compound powder of rhubarb, given to produce its laxative effect, may precede the other remedies. In some cases of irritative dyspepsia Ave will obtain much advantage from the use of small doses of Aconite, repeated every one en- tAvo hours for a day or two, anel afterwarel at less frequent intervals. The Avet pack to the abdomen may also be resorted to in more acute cases with advantage. In the simpler forms of atonic dyspepsia, I put the chilel on the use of some simple bitter, as an infusion of Matricaria Chamo- milla, Virginia snake root, or the Panax Quinquefolia. In others I prescribe Collinsonia alternated with tincture of muriate of iron in the following propen-tions : Py Tincture of Collinsonia oss., Simple Syrup .giijss.; half a teaspoonful three times a day. R Tincture of Muriate of Iron, oij., Glycerine, Simple Syrup, aa. to 5iv.; a teaspoonful three times a day. The tincture of Nux Vomica in small dose's, or a solution of strychnia in doses of about the l-200th to the l-100th' of a grain may be used Avith marked advantage. In some of these cases Podeiphyllin, thoroughly triturated, will prove one of our best remedies. As named in the first part, it should be triturated in the proportion of one part to ten or tAventy of sugar; have Ipecac triturated in the same way, anel combine them in equal parts, making poAvders of one-half to one grain. This may be given three or four times a day, and asso- ciated with the tonics, as before named. COLIC. AVe may distinguish tAvo forms of colic in children, the one being temporary and arising from slight indigestion, the other bearing a close relationship to the bilious colic of the adult, and due to spasnmdic contraction of the muscular coat. The first form is of very frequent occurrence, anel in some cases seems to be natural to the child. It comes on from the slightest causes, and lasting an hour or two, passes aAvay, and the chilel seems as well as ever. AVith many it Avill continue to recur frequently for the first three or four months, and will then cease. The second form of colic is caused by colel, by indigestion, by some indiscretion in the diet of the mother, or occasionally by 318 ' DISEASES OF CHILDREN. mental excitement, from anger, fear, grief, etc. The child not only suffers much pain, but there is functional disturbance, and some fever. Symptoms.— In either form of colic the child is uneasy, changes its position frequently, bends its body in various direc- tions, and cries persistently. Simple crying, hoAvever prolonged, would not be evidence of colic, but Avith the contortions of the body, and frequent change of position, the diagnosis is pretty evident. It may continue but a feAV minutes, or for half an hour. When it lasts long it is remittent or paroxysmal. The second form of the disease presents the same evidences of pain, but it is of longer duration, continuous, and severer. I determine its character principally from contraction of the fea- tures Avhich expresses pain. The flexion of the trunk, and of the lower extremities upon the abdomen is more persistent. Treatment.—In many cases the colic is speedily relieved by the administration of Nux Vomica, as—Py Tinct. Nux gtt. ij.. water 5iv.; a half teaspoonful every fifteen minutes or half hour. If the child is feverish, Aconite in the usual doses may be alter- nated with this. In other cases the indications will be stronger for Colocynth, and I usually administer it as fe)lloAVS : Py Tinct. Colocynth gtt. ij., Tinct. Aconite gtt. iij., Avater 5iv.; a teaspoon- ful every half hour. An infusion of Dioscorea, or of Epilobium, will sometimes give prompt relief, and sometimes the tincture will serve a good purpose If the attack is very severe, and relief is not obtained in this way, an enema of hot water (sometimes colel is better), or Avater to Avhich we have added grs. xx. of Compound PoAvder of Jalap and Senna may be used. Sponging the abdomen with hot Avater, the general hot bath, hot packs to the abdomen, a cold pack, if the temperature of the child is increased, a sinapism, or the application of chloroform, will suggest themselves to the practitioner, and will be selected according to the indications. In some cases the prescription of Lobelia with Comp. Tinct. Lavender may be used, more rarely chloroform may be given by mouth. If the pain is excessive chloroform may be used to produce partial anaesthesia and give relief. If Ave can not relieve the patieitt in any other Avay chloral may be given to relieve the pain until other means can be employed. DIARRHCEA. 319 If the child suffers from gastric irritation or dyspepsia, we Avill treat the case as has been named for those affections. And if owing to errors or imprudence in the diet of the mother, Ave will endeavor to have them corrected. DIARRHCEA. Simple diarrhoea is of very frequent occurrence with children, and Avill arise from any cause deranging the processes of digestion, or from cold. AVe recognize the same fenmis of the disease as in the adult; first, from irritation of the intestinal canal; second, from increased secretion of bile; third, from atony of the intestines; fourth, from congestion of the portal veins and determination e>f blooel; fifth, from increased secretion of mucus; sixth, from imperfect digestion. A simpler classification, hoAvever, and more easily recognizee! in practice, is the tAvo forms, diarrhoea from irritation and diarrhoea from atony. Symptoms.—In diarrhoea from irritation the discharges from the bowels are dark-colored, usually a shade of green, or in some cases of a light or pea-green. They are sometimes acrid, so that when they have continued for some time, they excoriate and chafe the chilel. Usually, the child manifests some uneasiness before having a stool, anel there is some straining Avith it. Occasionally, there is febrile action, the skin being harsh and the temperature elevated. In diarrhoea from atony, the discharges* are light-colored and watery, and passed Avithout any pain or uneasiness. They are usually larger than in the other case, though the amount of solid matter is not increased. Here, if it persists for some time, the child seems relaxed, the skin soft and cool, extremities cold, face pallid, and circulation enfeebled. In both cases the appetite is impaired if the diarrhoea con- tinues, and Avhat food is taken is not well digested, consequently the patient loses strength and flesh as the disease progresses. Treatment.—The diarrhoea of irritation may be very fre- quently controlled by the use of Aconite alone, in the usual doses. Generally Ave continue Ipecac with it in the folloAving proportion : R> Tinct. Aconite gtt. iij., Tinct. Ipecac gtt. v., Avater ^iv.; a teaspoonful eATery hour. The Euphorbia Hyperi- cifeilia will sometimes prove a better remedy than Ipecac, and 320 DISEASES OF CHILDREN. may be substituted for it in about double the proportion. If the patient complains of uneasy sensations in the abdomen, with tormina anel some tenesmus, the prescriptiem might be: R Tinct. Aconite gtt. iij , Tinct. Colocynth gtt. ij., water o'iv.; a teaspoonful every hour. In atonic diarrheea wc frequently substitute Nux fe>r the Aco- nite, as: Py Tinct. Nux Vomica gtt. iij., Tinct. Ipecac gtt. v., Avateroh'.; a teaspoonful every hour. AVhen there is evidence e>f irritant matters in the intestinal canal, an infusion of compound penvder of rhubarb may be given to produce an action upon the boAvels, anel afterwarel in smaller doses until the diarrhoea ceases. Or, after obtaining this-actiem, we may use the subnitrate of bismuth, in doses of one to three grains, every two or three hours. In atonic diarrhoea, we may use the preparation of rhubarb, above named, to change the character of the secretions; or in its place: Py Neutralizing Cordial 5ij., Chhiroform 5ss.; a tea- spoonful every hour. Podophyllin thoroughly triturated with prepared chalk, is an excellent remedy in these cases, Avhen given in minute doses, say the 1-40 of a grain. If an astringent is thought desirable, tannic acid with glycerine will answer a ge>oel purpose, and will be readily taken by the chilel. It may be dis- solved in the pronortion e>f 5j- to the ounce, and given in doses of one-fourth to one-half teaspoonful. If the tongue is pallid, the patient should have bicarbonate of soda,or in some cases lime Avater, Avhatever else may be given. If the tongue is deep-red, an aciel should be given, usually muriatic acid. If the tongue is reel and dirty, the remedy Avill be sul- phurous acid. Leptandrin is an excellent remedy in those cases in which there is evident torpor of the liver, and Avould be preferable to the Podophyllin, Avere it not that the dose has to be large, anel the remedy is very unpleasant. Stimulants, especially the aro- matics, may be used in some of these cases, but as a general rule, they are not so beneficial as in the adult. MUCO-ENTERITIS. Subacute inflammation of the small intestine is most usually caused by cold, though it may arise from irritating ingesta, or from decomposition of the food and the production of irritant MUCO-ENTERITIS. 321 material from this. The inflammation is confined mostly to the mue-e)us membrane, the secretions of which are increaseel, anel an increased peristaltic action having been set up, there is more or less eliarrhcea. Symptoms.—The child is restless and uneasy, anel has consid- erable fever. The elischarges from the benvels are not at first very frequent, but they are preceded by pain, the child flexing the body anel the lower extremities to remove the pressure. The discharges are attended Avith some tensemus, and in some cases the straining will be quite severe and prolonged. The stools vary in character; in nursing children they at first consist of curded milk, mixed with a greenish feculence, afteiAvard they contain mucus, and are slimy and tenacious. In other cases the stoeds will be a green or brownish frothy material, mixed with mucus. As the disease progresses the discharges from the bowels be- come more frequent, and are attended with greater uneasiness. They also contain more mucus, indeed sometimes seem to consist almost entirely of it. The febrile reaction also continues, and sometimes becomes quite severe. Generally it will run its course in from six to eight days, the fever ceases, the inflammation of the bowels passes away, and the diarrhceal evacuations stop. Diagnosis.—We diagnose a muco-enteritis by the febrile reac- tion Avhich comes on with the diarrhoea, and by the tormina anel tensemus which attend the elischarges. From dysentery it is distiiiguisheel by the feculence of the elischarges. In some cases the diseases are associated, anel we have a true dysenteric diarrhoea. Treatment.—The treatment of this form of diarrhoea is very simple. AVe put the chilel upon the use of Tincture of Aconite gtt. ij. to gtt. a\, Tinct. Ipecac gtt. v. to gtt. x., Avater Siv.; a teaspeionfnl every hour. In place e>f the Ipecac the 'Euphorbia may be used. If there is much griping pain, Ave will sometimes find Colocynth, the'best remedy, as—ly Tinct. Aconite, Tinct. Colocynth aa. gtt. iij., Avater %\v.; a teaspoonful every hour. In some cases there Avill be nausea, not controlled with Aconite anel Ipecac and in examining the patient Ave Avill note the ex- pressionless mouth, and the pallid atonic tongue, anel Nux in small doses will be suggested until these symptoms have passed aAvav. AVhen the tongue is broad, pallid and dirtv, the patient 21 322 DISEASES OF CHILDREN. has sulphite of soda ; if deep red, an acid is given. In some cases the marked periodicity in the disease calls for quinine, and it is given in the usual antiperiodic doses. Among the older means that may be suggested are the white liquid physic, when there is much tormina and tenesmus; tritu- rated Podophyllin, or the compound poAvder of rhubarb, when the discharges are light-colored, and the boAvels tumid; bismuth, either in the form of sub-nitrate or liquor bismuth, or an infusion of Epilobium. In some cases where the fever runs high, I have given the Veratrum instead of Aconite, and where there was much irritation of the nervous system, adding Gelseminum. CHOLERA INFANTUM. Cholera infantum is a disease of the second year of childhood— a period which may be considered one of the climacterics of life, as there is uoav a change from the fluid food obtained from the mother, to the ordinary food of man. The change is a great one, but Avhen there is strong vitality and good development, it is made Avithout any appearance of disease. But if from any cause the child is enfeebled, or its development in other respects is tardy, it then suffers in the way Ave are about to describe. It is not easy to say what the exact pathology of this disease is. In one case it seems to be almost wholly an irritation of the gastro-intestinal mucous membrane; in another it is an atonic condition, and a failure of power to digest food ; in another still, the intestinal lesion seems to be secondary, and depends upon a Avant of assimilation and nutritive poAver; and in others the lesion is principally of the nervous system. I conclude from all this, that the lesion is primarily one of the sympathetic system of nerves Avhich govern all the processes of vegetative life. In all cases there is debility, though in one it may be manifested in irritative action, and in the other in atony. Many have urged dentition as the cause, but as this is a phys- iological process, except Avhen disturbed, Ave Avould expect to finel the disease only in cases of dental irritation, whereas Ave find it in children aamSo haATe no teeth, avIio are not cutting teeth at the time the disease commences, who have all their deciduous teeth except the four last molars, or Avhen showing no swelling, ten- derness or irritation of the gums. CHOLERA INFANTUM. 323 Cholera infantum usually occurs in the summer, making its appearance in May, June, or July, and in the severer cases last- ing until frost and cool nights in the fall. A continuous high temperature always increases the severity of the disease, while a moist cool atmosphere gives relief. As a general rule, it is more severe on Ioav lands than on high ground, and is unfavor- ably influenced by the ordinary malarial causes. Symptoms.—AVe may divide the disease into two varieties, acute and chronic; the first bearing a very close resemblance to the cholera morbus of the adult, the second progressing sloAvly and occupying a period of Aveeks or even months. Acute cholera infantum is usually precedeel for a day or tAvo by a slight diarrhoea, Avhich gives the child but little uneasiness, and is scarcely noticed by the mother. But presently the child manifests an intense desire to drink and greedily takes Avhatever is offered. This causes nausea and vomiting, and the fluids are throAvn up about as soon as taken. The diarrhoeal discharges also become more frequent, and are large and exhausting. In a very short time the child is much prostrated, there is fre- quent retching and vomiting, especially when any thing is taken upon the stomach. The thirst is a very marked feature, the child Avanting Avater all the time, and crying for it AvheneA-er it sees a cup or glass; yet if even a tea-spoonful is taken, it is thrown up. The evacuations from the boAvels haA-e also increased in fre- quency. In some cases the skin is harsh or dry, and the pulse hard and increased in frequency ; in others the skin is soft and doughy, the extremities cold, and the pulse feeble and frequent. Occa- sionally the brain is affected, there being congestion or a low form of determination, or effusion. I recognize these cases by the extreme restlessness when there is determination, and a con- tinued rolling of the head from side to side, and stupor in the other cases. The disease may terminate fatally during the first tAventy-four hours, or may continue for three or four days—the child recov- ering—or gradually pass into the chronic form. The chronic form of cholera infantum may folloAV the acute attack, as above described. But in a majority of cases it is pre- cedeel for a Aveek or tAvo by a simple diarrhoea, Avhich, as it does not make the child sick, is alloAved to progress without attention 324 DISEASES OF CHILDREN. The very gradual increase in the disease is probably the reason why an early treatment is not adopted. The disease develops by an increase of diarrhoea, and the ap- pearance e>f nausea and vomiting. The chilel has lost flesh and strength, its appetite is impaired, and it is thirsty, Avanting to drink frequently anel considerable quantities. As time passes, all the symptoms increase, but those that are especially marked are the intense thirst, irritability of the stomach, with frequent vomiting, especially Avhen drink or food is taken, frequent evac- uations from the boAvels, anel great loss of flesh and strength. The discharges from the boAvels vary much in character in different cases, and even in the same case at different times. Sometimes they are yelloAvish, with more or less stringy mucus mixed with them, shoAving disease of the mucous follicles; at others they are greenish, ami have a sour smell ; at others clayey; again almost Avhite, and rarely a dark broAvn or black.* In febrile cholera infantum the skin is harsh, dry and con- stricted, anel in some cases seeming to be draAvn upon the pa- tient like parchment. There is great irritability of the nervous system, the patient being restless anel uneasy, never satisfied, ahvays changing its position, Avanting everything, satisfied with nothing, and especially restless and wakeful at night. The child seems to be Avorse in the afterpart of the day and evening, and frequently every other day. AVhen the disease becomes very severe, it is impossible to keep the child in bed at night, the heat seems to torture it, and it is only satisfied Avhen laid Avhere it can turn freely about, or when carried from place to place. In the non-febrile form the skin is soft, relaxed, and flabby, the extremities cool, the bowels distended or pendulous, the tongue broad, flabby, and coated, and the pulse small, soft, and fluent. The child is not so restless as in the preceding case, seems stupid and dull Avhen nursed in a comfen-table position, but Avants its *Dr Go'dingBird made an analysis of the green evacuations of children. and found, contrary to what was generally supposed, that they gave no indication of containing an excess of bile. He conceives that their color is due to the presence of altered blood, and that the state in which they are produced is analogous to that which exists in melaena, the portal system being generally in a congested state, In support of his views, he mentions that stools original'y of a yellow or orange color, often turn green on exposure to the air, an occurrence very unlike what takes place with matters containing bile, though it is an ascertained fact that blood, under the influence of several oxidating agents, acquires a green color. CHOLERA INFANTUM. 325 oavii Avay. In hoth cases the appetite is alike impaired, there is the same nausea, the same desire for drink, and the same pros- tration of strength. \Are sometimes find the brain affected in those cases Avhere there is a continued moving of the head from side to side, the chilel sleeping with its eyes partly open, and rolling the eye- balls upAvard. If the pupils are somewhat dilated anel do not contract freely, upon exposure to light, I am satisfied there is congestion with effusion, and consider the patient's prospects very poor. Occasionally determination to the brain sets in, the heael is hot, there is throbbing of the carotid arteries, contrac- tion of the pupils, anel great restlessness and uneasiness. As the disease lasts for Aveeks, sometimes the Avhole summer, it eloes not present these active symptoms throughout. There are remissions and exacerbations ; for a few days the vomiting will cease, the appetite improve, anel the diarrhceal discharges are less frequent—consequently there is a marked improvement in the child. Then, from some slight indiscretion in diet, or over-ex- ertion, but more frequently from alternations of temperature, there is another exacerbation. Diagnosis.—The acute attack is readily recognized by the sudden appearance of nausea, vomiting, anel diarrhoea, the great prostration, and intense thirst. The chronic form, by its sIoav accession, and the same nausea and vomiting, the intense thirst, the persistent diarrhoea, and the impairment of digestion and nu- trition, as marked by the rapidly Avasting tissues. Prognosis.—The first element of prognosis with me is to de- termine the viability of the child, anel I am guided in this by the depth of the base of the brain, as determined by the life line heretofore described. If the child has good viability, no matter hoAV severe the disease, I am hopeful, anel give a favorable prog- nosis. But if the life line falls below half an inch the prognosis is very doubtful. The prognosis is less favorable when the brain becomes in- A^olved in the disease, presenting either irritation or congestiem. Cases, also, which have been treated with irritant medicines, or by the persistent use of astringents, are difficult to manage. Treatment.—The treatment of the acute form Avill be much like that for cholera morbus of the adult. The objects are to 326 DISEASES OF CHILDREN. arrest the vomiting, to check the diarrhoea, and to restore tone to the system. To fulfill the first indication Ave have a large list of remedies, and, as is generally the case Avhere there are so many remedies, there are none very certain. I think this Avill apply, however, to the medicines in ordinary use, anel not to specifics. I Avill name the first in the order in which they are most commonly employed. Py Rhubarb, Bicarbonate of Soda, Spearmint, aa. This, as wil 1 be recollected, I recommend in place of the ordinary neutralizing powder of the Dispensatory. AVhen the patient is first seen, add ten grains of the poAvder to ten teaspoonfuls of cold Avater, and alloAV it to settle; give a teaspoonful every ten minutes. Add a teaspoonful of the poAvder to one-third teacupful (tAvo ounces) of boiling water; let it stand until cool, strain, SAveeten, and if the child is someAvhat exhausted, add a teaspoonful of brandy. As soon as prepared give half teaspoonful doses every half hour, and as it is retained, increase the dose to a teaspoonful every hour, until it acts slightly upon the boAvels. The first doses will be thrown up, but by repeating them it quiets the stomach and the nausea and vomiting cease; if not, after passing a reasonable length of time, select another remedy. An infusion of the bark of the young twigs of the peach tree is a very reliable remedy in these cases, and may be given in small de>ses, frequently repeated, until the object is accomplished. The subnitrate of bismuth in mint Avater, Avill prove a good remedy in some cases; it is used in the ordinary doses. In those cases Avhere there is marked exhaustion, the extremi- ties being cold, stimulants answer a better purpose than other remedies. The compound tincture of Cajeput is a good remedy in these cases. If not convenient, a tincture e>f the essential oils of cinnamon, cloves, peppermint, etc., singly or in combination, may be employed; or tincture of camphor may be used for the same purpose. Chlorodyne, the formula for Avhich is given in the first part, may sometimes be given with advantage, in doses of about one to two drops. Chloroform may also be used, and will sometimes be tolerated when other remedies are not borne. Whatever is given, or Avhether anything is given, the nursing is a most important part of the treatment. Place the child in the recumbent position, and wrap the feet in drv, hot flannels, keeping a plate, stove-lid, or any heat-retaining article in con- tact with them, so as to keep a continued heat. If there is feeble CHOLERA INFANTUM. 327 circulation, and marked coldness of the extremities, the poAvdered capsicum or mustard may be sprinkled upon these flannels. As an application over the stomach, I prefer the cold pack, either in the form of a Avet towel folded, Avhich may be renewed as often as may seem necessary, or an entire abdominal pack, Avhich will remain for one or two hours, and will then be removed, the child rubbed thoroughly, and Avrapped in dry flannel. The recumbent position should be insisted upon. To quiet the thirst, I prefer giving small pieces of ice, or tying a piece in a cloth for the child to suck. If ice can not be had, then give cold water, a teaspoonful at a time, every feAV minutes. Sometimes a very little salt added to the Avater causes it to be retained better. AVhen the vomiting is persistent, and the thirst excessive, I have employed an injection e>f salt Avater with good advantage It is used in considerable quantity, and may be repeateel Avhen it passes away. AVe have now to speak of specific remedies for this disease, and though they arc imt cure-alls, they deserve attention. AVhen the skin is hot anel dry, the pulse hard, and e>ther evidences of a febrile condith)ii, Aconite is the remedy. I use it in the ordinary proportion of tAvo drops to Avater four ounces, but give one- fourth of a teaspoonful every fifteen minutes. The directions above as to nursing, must be implicitly folloAved. In an ordinary case, I order Aconite and Ipecac alternately; they are prepared for use by adding tAvo drops of Aconite and five drops of Ipecac to four ounces of Avater, and give a teaspoonful every hour. They may be a little sIoav but are very certain in their action. AVhen the face is pallid, and the mouth expressionless, the tongue pallid and atonic, Nux will serve our purpose best. It is given in quite small doses, gtt. j. to gtt. ij. to Avater Siv.; a tea- spoonful every fifteen minutes until the nausea is quieted. The Ipecac is added in the usual proportion, and the tAvo are continued until the diarrhoea stops. It is a little singular, but there is in the market much so-called " fluid extract" of Nux Vomica, that has no bitterness, and of course is absolutely Avorthless. Such stuff is not recommended. In the acute form of the disease Ave have accomplished the greater part of the cure, when we have arrested the nausea and vomiting, and generally any simple remedy adapted to the case, 328 DISEASES OF CHILDREN. Avill be sufficient to arrest the diarrhoea. In my practice I depend almost avholly upon the continued use of Aconite and Ipecac. In true cholera infantum (chronic) it is well te> make the clas- sification of cases—irritative and atonic. Sometimes this is very readily done, as the symptoms are so marked, but in others Ave reach a half-Avay ground, a debatable land, and the classification can not be maele. In some cases the irritation of the stomach is extreme, so that the child can take neither food nor medicine with advantage. Aconite and Ipecac in very small doses, with restrictions in drink, (thirst is extreme,) will frequently relieve the stomach. Some- times Euphorbia is substituted for the Ipecac, or if there is much tormina and straining at stool, Colocynth may be used. The dose of course must be very small. Py Tinct. Aconite, Tinct. Colo- cynth, aa. gtt. ij. water 5i\\; a teaspoonful every hour. (The medicine should be kept cool, and prepared fresh every day.) If the tongue is pallid, the face expressionless, and salloAV or yellow about the mouth, Nux Vomica will be the remedy to re- lieAre the nausea. One or tAvo drops may be added to a half glass of water, and given in doses of one teaspoonful every half hour or hour. Ipecac may be added in some cases to assist in relieving the nausea, or after a'day or two to centred the diarrhoea. The Compound Powder of Rhubarb, infusion of Peach bark, Bismuth, Hydrate of Chloral, and sometimes, but rarely, stimu- lants may be employed, as heretofore named. In some cases Ave finel marked irritation e>f the brain, and indi- cations for Gelseminum. In others the patient is dull and stupid and Belladonna is wanted. There are cases in which the child is extremely restless, starts in his sleep, aAvakes frightened, cries out shrilly, and at the same time has a peculiar pinched expression about the eyes and base of the brain. The symptoms are char- acteristic, and the remedy is Rhus, and when thus indicated it Avill quiet irritation of the stomach, and check the diarrhoea. There are cases in Avhich sulphurous aciel becomes an excellent remedy; cases that require sulphite of soda ; cases that want a simple'alkali, bicarbonate of soda or lime water; and others that Avant muriatic acid. Here, as elsewhere, the indications for rem- edies should be followed. Podophyllin thoroughly triturated Avith sugar of milk or loaf sugar, in minute doses, is sometimes an excellent remedy. Its use is in those cases in Avhich there is atony of the stomach, and CHOLERA INFANTUM. 329 congestion of the liver and portal circle. Cases in which the tongue is broad, and coated, the abdomen swollen, the skin salioAV. and the temperature lowered. Leptandrin is used in these cases, but is not so easily taken by children, and owing to its nauseous taste, is not so Avell tolerated by the stomach. In cases where there is any evidence of periodicity, usually manifested by increase of nausea and vomiting and diarrahoea, quinia may be employed with advantage. I prescribe it as I do in intermittents, every two hours, until three doses are taken, or one dose of two grains, at the time when the patient is most free from nausea. Iifsome cases its action is very decided—it checks the nausea and vomiting, lessens the thirst, allays the irritation of the nervous system, and indeed, seems to impnwe every func- tion ; and repeated for a few days, the patient is convalescent. In some cases minute eloses of Arsenic with Veratrum will quiet the gastro-intestinal irritation, and strengthen digestion better than anything else. AVhen there is a soft compressible pulse, a relaxed and pale skin, ami cold extremities, I have used the quinine inunction with benefit. I think in some very bad cases, it has given tone to the system, and so added to the patient's power to live, as to tide over the summer to frost, and convalescence. Fatty inunction alone, answers a very good purpose. When the skin is dry and harsh, it is the best means to soften it anel place it in conelition for secretion. AVhen it is soft and relaxed, by adding a stimulant to it, and using it nvith friction, it is a good means to stimulate capillary circulation. I do not like the free bathing sometimes recommended, as there is not the power of re-action, Avithout Avhich the use of Avater must do harm. If the chilel is bathed, let it be thoroughly anel quickly Avashed with soap anel Avater, or Avith salt and Avater, if the inunction is not practiced. In semie cases of cholera infantum a soft flannel bandage is applied to the abdomen, anel gives as much relief as the medicine. A bag, a foot square, filled with ge>od Fenugreek seed, sprinkled with oil of cloves, or some other of the essential oils, and quilted a half inch thick, and worn over the stomach, will give marked relief in some cases. It is after the order of the old fashioned spice plaster, but is better. Much will depend upon the diet of the chilel in some cases. As a general rule, the mother's milk is preferable, and the case 330 DISEASES OF CHILDREN. would be exceptional where I Avould recommend that it be weaned; still there are such cases. AVhen the child has been weaned, hoAvever, Ave will have to take this into consideration. The directions heretofore given will enable us to determine Avhether the milk in use is good. If Ave see reason to change this, Liebig's food Avill be found the best, Avhere it can be taken. RaAv or rare cooked beef Avill sometimes agree avcII v ith a child Avhen it has been unable to take other food. Pickled pork will sometimes ansAver well, and be digested when the stomach will not tolerate lighter articles of food. The child's appetite may be gratified, and indeed it may be taken as a guide, with refer- ence to all such things as constitute the healthy food of the country, only excepting some vegetables and fruits. In regard to the latter, we have difficulty sometimes in determining Avhether any, or Avhat may be given Avith safety. As a general rule, ripe peaches and blackberries, fresh from the vines, will be the only ones Ave can give with safety. The excessive thirst is an annoying feature of the disease, and Ave Avill be anxiously asked about gratifying it every time Ave see the patient. In some cases the child may have all the Avater it wants, even though it causes vomiting at first, feTr by giATing drink freely in this Avay the irritation of the stomach is overcome, These cases, I am sorry to say, are feAV. The rule of practice is. that the child must be restricted to small quantities of Avater until the disease is arrested ; it may be given frequently, however, and this is some alleviation of the thirst. In other cases, when the stomach refuses to tolerate water Ave order ice, and it may be given quite freely Avithout danger, and sometimes with benefit. Recollect the injection of salt Avater in these cases, and the ad- vantage that sometimes folloAvs from the use of the Avet-pack. Convalescence must be managed Avith care, and indiscretions in diet avoided. I frequently put the little patient on the use of tincture of muriate of iron and glycerine, as heretofore named, and sometimes associate it with phosphate of soda, three grains, three times a day. TABES MESENTERICA. Tuberculous disease of the intestinal canal is most usually met with in childhood, though occasional cases will be seen even up to the age of twenty-five. It occurs only in those constitu- TABES MESENTERICA. 331 tions which Ave have before referred to as being tuberculous, and where, if the irritation had been of the lungs instead of the boAvels, it would have been phthisis. The pathology of the disease is Avell described by Habershon : " In disease of the mesenteric glands, a Ioav organized product is effused into the glands themselves, probably because the chyli- ferous ducts become entirely obliterated, and the structure of the gland destroyed. Their extensive disease prevents the absorption of chyle into the system. The glands share the disease in vari- ous stages and gradations ; in some, but scanty abnormal product is found, in others the Avhole gland is destroyed and very much enlarged, constituting a Avhitish mass, the size of a pigeon's or hen's egg. The effuseel product cemsists of granular blastema, and imperfectly developed cells. The swollen anel injected state of the glands less affected, appears to indicate that inflammation or hyperaemia is associated with the disease. The increase takes place by additions to the periphery of that already deposited, anel degeneration occurs in the center from the scanty supply of nourishment afforded to the central part. The gland sometimes appears to be enveloped by a firm, fibrinous cyst, which consists of inflammatory product better organized, having assumed the character of fibrous tissue, Avhile the center consists of calcareous deposit, the albuminous portion having been absorbed, and the organic only left. Degeneration of another character, however, takes place in the effused product, it is converted into a mass of granular molecules and highly refracting particles, constituting small, cheesy tubercles of a yelloAV color, or a softened and semi- diffluent mass. The lacteals betAveen the glands become enlarged anel distended with similar strumous product, or Ave can trace the distended ducts to the intestine, where they ramify on its surface, and at this part Ave generally find a cluster of tubercles and ulceration of the mucous membrane." Symptoms.—Tn children it is usually preceded by diarrhoea and gradually increasing prostration. The appetite is usually good, sometimes ravenous, but the patient receives no apparent benefit. The boAvels are sometimes tumid, hot anel tender, at others very much shrunken ; the evacuations consisting of a thin mucus, greenish, anel frequently resembling the washings of meat. The countenance is contracted and pinched, the eyes set far back in the head, and the skin peculiarly dry, wrinkled, and salloAV, 332 DISEASES OF CHILDREN. giving the child a prematurely aged appearance. It is restless, irritable and fretful, and presents many of the symptoms of cholera infantum. In the adult there may or may not be diarrhoea, frequently an alternation of diarrhoea and constipation, and sometimes severe pain. There is a marked marasmus, increasing day by day, though the appetite may be good, and the digestion seemingly avcII performed. The patient has an anxious expression of coun- tenance, a salloAV, Avrinkled skin, contracted abdomen, and is Uneasy, restless and irritable. In the latter stage diarrhoea some- times sets in, anel carries the patient off quickly, or disease of the brain or lungs comes on to assist the tabes. In both cases the enlarged mesenteric glands can frequently be felt through the abdominal Avail. Diagnosis.—Tabes mesenterica is diagnosed with difficulty. The principal symptoms leading us to believe in strumous dis- ease of the mesentery are: the continuance of a good appetite, and seemingly ge>oel digestion, with continually increasing loss of strength and flesh, and the evidence of disordered boAvels, anel in the latter stages feeling the enlarged mesenteric glands.through the abdominal Avails. It will be seen that our diagnosis will have to be made principally by exclusion, a very common method, anel possibly more correct than by direct symptoms. Prognosis.—The prognosis in Avell marked cases of this dis- ease is exceedingly unfavorable, as much so as any disease we are called to treat. In the earlier stages its progress may be arrested as it may also occasionally in the latter. Treatment.—A tonic and restorative treatment would seem to offer the best results in these cases. Yet Ave find that it does not prave so serviceable as some other means. The general inunction with quinine once a day, and the use of the Uveelalia ointment to the abdomen is recommended. In some cases small doses e)f Arsenic exert a beneficial influence as : R FoavIit's Solution gtt. x., Tinct. Veratrum gtt. v., Avater 5iv. ; a teaspoem- ful every three or four hours. Hypophosphite of lime is a good remedy, as is the compound syrup of the hypophosphites ; cod-liver oil has given very good results Avhen it could be taken Avell anel digested. In some cases a good preparation eff malt, taken after the foods, aids in digestion, and the child will improve on it. dysentery. 333 Small doses of Ipecacuanha, alternated with Aconite, may be employed te) relieve the irritation of the boAvels, and check diar- rhoea when it is present. Or, in place of these, Ave may use the extract of Hamamelis (Pond's), which I think very highly of. The dose will be about \cn drops four times a day. The use of Alnus, Rumex, Scrofularia, and others of our vege- table alteratives, has been recommended ; but I think they Avill not prove so serviceable as the means above named. DYSENT V R Y. Inflammation of the large intestine in the child arises from the same causes, and presents somewhat similar symptoms to the same disease of the adult. It occurs in both the sporadic and epidemic form, though in some epidemics children are remarkably exempt from it. Indeed, as a general rule, we will find that dys- entery in the chilel is rarely the active inflammatory affection that Ave are called to treat in the adult. Causes.—The common cause of sporadic dysentery is colel, though it may be produced by indigestible food, or such derange- ment of the digestive process as Avill permit the decomposition of food and formation of irritant products. Epidemic dysentery depends upon the influence of an animal poison; Avhat it is Ave do not know, nor Avhy it acts upon this particular portion of the body. Pathology.—Dysentery is a true inflammation of some por- tion of the large intestine—a colitis. The inflammation may involve but a small portion of the intestine, anel be confined to the mucous membrane, or it may involve the greater part or all, anel exteml to the muscular and peritoneal coats. There are some cases in children in which the inflammatory character is not marked, but rather an irritation of the mucous coat, Avith increased secretion, and of the muscular coat, Avith increased peristaltic movement. This form e>f the elisease is not attended by fever, and may continue for Aveeks or months without danger to life. Symptoms.—Tn acute sporadic dysentery of the child, it is first noticed that the boAvels are moving too frequently, ami there is considerable straining at stool. The discharges, hoAvever, are 334 DISEASES of children. feculant, though small, but if noticed closely they Avill look slimy, and after a day has passed they will be almost pure mucus, or mucus tinged Avith blood. As the dysenteric character of the discharges becomes marked, febrile symptoms appear. The child is restless and uneasy, the skin is dry, the pulse is accelerated and hard, the appetite im- paired, and indeed all the functions of the body deranged. These symptoms vary greatly in different cases—in some the fever runs high, in others it is hardly noticed. But as the disease progresses the discharges become more fre^ quent, every fifteen, ten, or even evTery five minutes; they aro preceded by pain, and attended with tenesmus. This straining at stool is so marked a feature with the child, and so strongly expressed in its countenance, that it is an index to the character of the disease as soon as seen. Day by day the child loses strength, and the general anel local disease seems to gain inten- sity, until the fifth or sixth day; then there is a gradual amend- ment, until convalescence is completely established. I speak of this as being the usual course of the disease when not influ- enced by medicine. Epidemic dysentery presents the same symptoms that it does in the adult. Commencing with evidences of prostration, and impairment of the general health, there is usually a Avell marked chill, Avhich is folloAved by febrile reaction. This general dis- ease assumes so prominent a place at first, that it overshadows the local inflammation. Yet, at first, there is an irritation and increased activity of the boAvels, and with the development of the*fever, the small mucous or bloody dysenteric evacuations be- come marked. It is not Avorth Avhile in this place to enter into a lengthy de- scription of the symptoms presented, as they are a continuation of those above described, with a remittent or continued fever. As the disease progresses, it develops typhoid symptoms, both general and local, and in the severer cases it becomes a very grave affection. The dysenteric irritation referred to when speaking of the causes of this disease, presents but a part of the symptoms of dysentery. The discharges are attended with straining, are small, and in some are Avholly mucus, in others mucus mixed with feculant matter. They are also frequent, and in some cases it seems that the child can not stoop or be placed in a constrained DYSENTERY. 335 position without an action of the boAvels. But the general health is less affected than Ave would suppose, not nearly so much in most cases as in ordinary diarrhoea. Still, as it continues for a longtime, it is a cause of much annoyance to both parents and physician. Diagnosis.—The diagnosis of dysentery is made with ease. No one could see the peculiar expression of countenance during the tenesmus, Avithout at once recognizing what Avas the matter, even if he had never seen a case of the disease. Prognosis.—The prognosis is favorable in the sporadic dys- entery of children, but in those epidemics that reach children the mortality is greater than in the adult. Treatment.—In the mild sporadic form of the disease, my practice resolves itself into the administration of Aconite Avith Ipecac in the usual doses. The general bath is used, and the hot foot-bath, and the child is kept still, and in some cases a cloth spread with lard or mutton suet is applied over the abdo- men. The treatment is very simple and very satisfactory, and I should be glad if all treatment Avere as much so. When there is persistent abdominal pain or tormina, I, like the action of Cedocynth, in the small doses heretofore named. In some cases Veratrum may be used, and if there is evidence of determination of blood Gelseminum is given Avith it. In some cases the broad pallid and dirty tongue calls for sul- phite of soda, and it is given in doses of from tAVoto five grains every three hours until the tongue has cleaned. Sulphurous acid is an excellent remedy in typhoid dysentery, the tongue being red and full, and covered Avith a nasty glutinous coat. In the olden time, the white liquid physic of our Dispensatory, held a prominent place in the treatment of dysentery. And it may yet be used with advantage in some seasons. I advise that the proportion of acids be diminished as follows: ly Sulphate of soda Sviij., water gxxiv., Nitric acid, Muriatic acid, aa. ^ss. Mix. The dose for a child two or three years old will be a teaspoonful every two hours, (with syrup), until it moves the boAvels gently, then in smaller doses. In some cases olive oil may be used to move the upper intestine. Tf ii a malarial region, Ave look carefully for periodicity, Avhich wi 11 be found in many cases. Here quinine is an indispensable 336 DISEASES OF CHILDREN. remedy, the patient being prepared for it, and it is given in the usual eloses. In some cases Ipecacuanha may be prescribed alone, triturated Avith powdered gum arabic, which is a good form, or combined with bismuth, as: ly Subnitrate of Bismuth, oss.; Ipecac gr. i v.; mix anel divide in eight poAvders, giving one every one or two hours. The same treatment is employed for the local lesion in the epidemic form of the disease, and in addition such remedies as Avill antagonize the septic tendency, and give tone and support to the system. These haAre been fully described under the head of continued fever, to Avhich the reader is referred. In some e>f these cases the Ipecacuanha seems to fulfill nearly all the indica- tions, and it is given with the best results. In others the use eif white liquiel physic to the extent of gentle purgation, afterwarel in smaller doses, answers best; and in still others Ave obtain the best results from bismuth. In dysenteric irritation we find a very stubborn case, and one that sometimes refuses to yield to remedies, literally Avearing out. I place most dependence upon the continued use e>f minute doses of Aconite, for several days ; next upon the u^e of the subnitrate of bismuth. Occasionally Ave find a case' in which there is evident relaxation of the rectum, Avith congestion, and in such the fluid extract of Hamamelis Avill prove very gooel. The h)cal means will consist of cold packs to the abdomen, the disease beingsthenic anel the patient carrying a high temper- ature ; or hot packs, or sponging the abdomen, if the disease is of a loAver grade In semie cases a hot sitz bath gi\res relief, and the patient has rest and sleep fe>r a feAV hours. In some cases Ave are obliged to use enemata to get rest fe>r the inflamed bowels, and exhausted patient. Sometimes Avater as warm as it can be borne serves a good purpose, but usually we think of tinct. Opium gtt. v. to x., starch Avater 5ij- to 5ss.—this is repeated after each evacuation. CONSTIPATION. Constipation is an attendant on many acute diseases, and is generally to be regarded as a favorable indication, though Ave may haA-e to use means to overcome it. It is also met with as an idiopathic affection, and it is this form that Ave Avish to consider. CONSTIPATION. 337 Infantile constipation seems, in a majority of cases, to be a con- genital defect in the irritability of the intestinal canal, rather than an acquired lesion. Thus we will find it manifested early, the child's boAvels ne>t moving for two or three days after birth, and continued on until by change of food, during the second year, a normal activity is induced. In some cases it seems to be de- pendent upon constipation of the mother, the acquired vice in her constitution manifesting itself in the condition of the child. In some others it is dependent upon the character of her food; but in the majority, we can give no reason for it, and we have simply the fact that constipation exists. Sometimes the constipation is attended Avith uneasiness in the abdomen and colic; but in the majority of cases the child does not suffer at all, but nurses Avell, and thrives like other children, and were our attention not called to it by the mother, we Avould not suspect anything Avrong. In some cases the child will make feircible efforts to stool, and may pass a small portion of hardened feces, at such times, or nothing may pass. Such at- tacks of tenesmus may come on three or four times a day, and are very unpleasant. Indeed, this is the only case that demands special attention. Treatment.—If the mother is of a constipated habit, we will be more successful in removing the torpor of the child, by such means as Avill restore normal activity to her, rather than by giving it medicine. The means I commonly employ are—that on first rising in the morning, a glass of cold water be taken, adding to it one or tAvo drops of tincture Nux Vomica; that the abdomen be thoroughly rubbed with the hand dipped in salt water; and that a regular time be set apart (immediately after breakfast is best) to evacuate the boAvels. Should this not be sufficient, ten or twenty grains of phosphate of soda may be taken in a glass of Avater, on going to bed. As remarked above, the medication of children to overcome constipation is not very successful, sometimes Ave will accomplish the object, at others we will be partially successful, and in others we Avill fail entirely. Phosphate of soda, in doses of two or three grains, three times a day, will occasionally ansAver the pur- pose, and the influence is usually permanent. Small doses of Belladonna may also be given, Avith the expectation of good results, in some cases. In those cases where the abdomen is re- 338 DISEASES OF CHILDREN. laxed and pendulous, Avith a torpid circulation, small doses of Nux Vomica will answer the purpose; and where the liver is inactive, Leptandrin, thoroughly triturated, may be given in doses of one-fourth to one-half grain. When the child suffers from tenesmus, it is Avell to move the bowels at first with olive oil or castor oil, and then follow with the means named above. Dr. Tanner remarks, that " since reading Corvisart's vieAvs on the action of pepsin, he has extensively used the remedy ; Avhich may be given to the youngest infant, in doses of three to six grains, dissolved in milk, tAvice daily. It seems to relieve con- stipation in the same Avay that it checks some forms of diarrhoea, by enabling the stomach to do its Avork thoroughly." If Ave use pepsin for this purpose, it will be quite as well to use ordinary rennet, giving the water in which it is soaked in quantities of one or tAvo teaspoonfuls, each time after nursing. I think the use of enemas and suppositories, in these cases, should be abandoned, as they are likely to do more injury to the rectum, than they do good in relieving the constipation. I have omitted to mention one thing which I regard as important in some of these cases, to see that the child's clothing is worn loose. Not unfrequently the band is put on so tightly as to paralyze the abdominal muscles, and I have no doubt that this is the principal cause in some cases. Thoroughly rubbing the abdomen with the hand, and a little lard, will prove beneficial in these cases. PROLAPSUS ANI. Prolapsus ani is met with most frequently from the age of two to four years, though it is sometimes seen during the first months of life. It comes on slowly, but as it is not noticed in its early stages, it seems to the mother as if it had Avholly developed Avithin a feAV hours. In almost all cases there is a softness and relaxation of the perineal tissues, which will be noticed as soon as the child is ex- amined. In some the sphincter ani seems mostly at fault, having so lost its poAver of contraction that it is not able to support the boAvel. AAre may recognize tAvo Ararieties of the disease: In the one there is this failure of the sphincter, and the entire bowel is permitted to descend, yet retaining its natural relation. In the other, the connectiA'e tissue betAveen the mucous and muscular PROLAPSUS ANI. 339 coats is relaxed, or has given way, and the mucous coat is ex- truded through the sphincter, which grasps it tightly. In this case the boAvel seems as if turned inside out. Symptoms.—In the early stages the child complains of uneasi- ness about the rectum, after going to stool, and if Avalking Avill be observed to keep the legs separated; but in a feAV minutes the bowel naturally retracts, and the uneasiness passes away. In the severer cases there is tenesmus during and after going to stool, and occasionally the child suffers severely. The boAvel requires to be returned artificially in order to give relief. If this is neglected it becomes congested and swollen, sometimes so much so, that elays Avill be required to so reduce its size as to permit a return through the sphincter. It is very easy to deter- mine what is the matter in these cases, as an inspection of the part shoAvs the bluish or dusky discolored tumor at the site of the rectum. AVhen the disease is of long duration, the skin and mucous membrane seem too large for their purpose, and the first hangs in folds outside, Avhile the second is gathered in folds inside. In some cases there is also an enlargement of the veins of the mu- cous coat, so that in consequence it is considerably thickened. Treatment.—The first object, Avhen called to a case of pro- lapsus ani, if the boAvel is still prolapsed, is to replace it. This is not always a pleasant job, yet it can be accomplished, e\Ten Avhen considerably SAvolleu, if care is used and the physician has patience. Have a soft cotton or linen cloth spread with lard, anel place-upon the protruding gut, the little patient being upon his hands and knees, or more frequently lying across its mother's lap, face doAvn, and feet depending. Noav placing both hands so that one or tAvo fingers may rest on the gut, the other fingers anel thumb press upon the perineum in such direction as to relax it. Gentle and continued pressure being made upward, in a short time reduction is effected. For the radical cure, if the case is mild, I direct that the part shall be washed with an infusion of Hamamelis, and that the distilled extract of the same (Pond's) be given in doses of five or ten drops three times a day; or in place of this, Ave may give the Collinsonia in doses of one drop three times a day. In some cases small doses of Nux, in others of Colocynth, and 340 diseases of children. in still others of Aloes, Avill relie\Te the tenesmus that causes the prolapse, and Avill strengthen the lower bowel and femoral muscles. In severe cases, when of long duration, I use the persulphate of iron as a local application. In- most cases one part of the solution to two or three parts of glycerine, will be as strong as it can be borne, but in others it may be used of full strength. The hypodermic injection of ergotin near the sphincter has given excellent results in cases otherwise incurable. There are a few cases Avhich will require operative interference. Two methods are practiced. In one the folds of skin alone are removed, in the other the entire projecting part—mucous mem- brane and skin. In the first case the operation is simple—the ordinary silk ligature having been passed through the base of the fold in tAvo or three places, this is cut aAvay with a pair of curved scissors or a bistoury, and the ligatures tied, bringing the cut edges together. Thus four, five, or six folds are cut aAvay, and when the part has cicatrized, it is much smaller and tense, and gives the needed support. In the other case the ligatures are passed through the projecting rectum, at distances of about one- half inch apart, leaving the ends sufficiently long to tie. The gut is then cut away outside of the ligatures, and when these are tied the cut surfaces are again in apposition, and cicatrization occurring, a very firm support is given, and the disease is readily cured. INTESTINAL WpRMS. The presence of Avorms in the intestinal canal is not ahvays attended by symptoms of disease; indeed children may enjoy very good health Avhile infested with these parasites. It has been claimed that an entirely healthy person will not have worms, as that an entirely healthy and well-taken-care-of child Avill not have pediculi. I think this is true, to the extent that the naturally healthy child will not suffer from them, and not furnishing a comfortable home they are not likely to remain. A depraved condition of the intestinal canal, Avith increased mucous secretion, seems to furnish the conditions necessary to the propagation of worms, and as digestion is necessarily inter- fered Avith by this condition, there will be more or less impair- ment of the general health. intestinal worms. 341 Causes.—Iu olden times it Avas thought that there Avas spon- taneous generation of worms, and there are some Avho yet hold to this opinion. The fact is, there is no new creation in this world; every organized body, from the simplest cell or monad to the highest animal life, being the product of parents who possessed the same form and functions. Intestinal worms, therefore, have a parentage, and are propagated only from the same species. The subject has been carefully studied for many years by Kuch- enmeister, a very persevering German physician and naturalist, and the facts are very clearly established. The tAvo varieties of ascaris and the trichocephalus are produced directly from ova taken into the intestinal canal, which, finding the conditions for incubation, are developed into the fully formed worm. Previous to this, it Avas belie\Ted that these vareties were viviparous— giving birth directly to the young. This was the opinion of Dr. Good, of Watson, and others. The taenia are oviparous, producing eggs from which the Avorms are developed. The development, however, requires tAvo animals of different species, in one of which the worm attains its pupa state, and in the second attains its perfect development. The process is very much like the development of a butterfly—from the egg to a grub, from that to a fully developed insect. Kuchenmeister traced the taenia solium from the cysticercus of the pig, through all its gradations up to the fully formed worm. These cysticerci are very tenacious of life, and may get into the intestinal canal by eating raw or partially cooked fresh pork, or even bacon. When once introduced into the human body, a neAv develop- ment commences, and from these small grub-like bodies are pro- duced the perfect tape-worm. Each joint of one of them con- tains a multitude of eggs, which being discharged with the in- testinal contents, regains its original habitat, the hog, is devel- oped into a cysticercus, which in turn by transplantation becomes a taenia. Thus from the fully developed worm in the human intes- tine is throAvn off the eggs, Avhich, being taken by the hog with its food or drink, gains access to its tissues and is developed into the cysticercus or grub, and this being eaten by men produces the perfect Avorm. This being the origin and mode of development, Ave find that certain sections of country are verminous, while others are com- paratively free. This has been remarked in case of the tape- 342 DISEASES OF CHILDREN. worm, and I think it just as\ Avell established with the other forms. When the conditions are favorable for the reception of the discharged ova in water or food, Ave will find that intestinal Avorms are common, and Avhere these do not exist they are rarely seen. The principal varieties of intestinal worms are: the ascaris lumbricoides, the ascaris or oxyurus vermicularis, the trichocephalus dispar, and the taenia solium and vulgaris. The ascaris lumbricoides, or long round worm, is described by Dr. Good as having a slightly iiicurvated head, with a transverse contraction beneath it; mouth triangular; body transparent; color, light yelloAv, with a faint line down the side ; gregarious, viviparous; from six to fifteen inches long; inhabits principally the ilium, but sometimes ascends into the stomach, and creeps out of the mouth and nostrils; occasionally travels to the rec- tum, anel passes away at the anus. The ascaris vermicularis, or small thread worm, has its habitat in the rectum, though it sometimes gets into the intestines, and occasionally in the female, into the vagina. " The head is subu- late, nodose, and divided into three vesicles, in the middle of which it receives nourishment; skin at the sides of the body finely crenate or Avrinkled ; tail finely tapering and terminating in a point; gregarious, viviparous, and about half an inch long." The trichocephalus dispar, or long thread worm, is found in the intestines, both large and small, and in the stomach, and especi- ally in sickly children, and those avIio are poorly nourished. " The body is obese, slightly crenate, beneath smooth, finely striated on the fore part; the head obtuse, and furnished with a slender retractile proboscis; tail or thinner part tAvice as long as the thicker, terminating in a fine hair-like point; about tAvo inches long, and its color light yelloAv." The taenia solium, or long tape worm, is described by the same author "as having long and narrow articulations, with margin- ons pores, by which it attaches itself to the intestines; one on each joint, generally alternate ; ovaries arborescent; bead with a terminal mouth, surrounded with tAvo toavs of radiate hooks or holders; and a little beloAV, on the flattened surface, four tuber- culate orifices, or suckers, tAvo on each side; it is from thirty to forty feet long, and has been found sixty. Inhabits the intestines of mankind, generally at the upper part, Avhere it feeds on the chyle and juices already annualized. Is sometimes solitary, but INTESTINAL WQRMS. 343 commonly in considerable numbers; and adheres so firmly to the intestines that it is removed with great difficulty. It is said to have the power of reproducing that which has been broken off; but this assertion Avants proof. The animal is oviparous, and discharges its numerous eggs from the apertures in the joints.' The articulations are from four to six lines in length, and nearly as much in Avidth, and resemble gourd or melon seeds. " The articulations of the broad tape Avorm are short and broad, with a pore in the center of each joint, and stellate ovaries around them ; body broader in the middle, and tapering toward both ends; head resembling the last; inhabits the upper part of the intestines, and feeds on chyle; from three to fifteen feet long > usually in familes of three or four." Symptoms.—With many if not all forms of worms, it is neces- sary that the boAvels be in a condition to furnish a comfortable habitation. This condition is essentially one of want of tone, with, in many, increased seeretion of intestinal mucus. We observe in many cases that the child or person is poorly nourished, the muscles are soft and flabby, there is a loaded tongue, bad breath, and derangement of the secretions. We are not inclined to believe that this is the result of Avorms, but simply coincident with them, and in some cases the patient has Avhat is termed worm fever, usually of an intermittent character, the paroxysms occuring in the afternoon and evening, at which time Ave find the skin hot and dry, the pulse frequent, the head hot, and marked irritability and restlessness, and occasionally convulsions. Or the fever may be more obscure, the child is fretful and nervous, sleeps poorly, its breath is fetid, tongue coated, bowels irregular, abdomen tumid, is frequently picking its nose, the upper lip swells, a white line appears around its mouth and it seems to be out of order generally. These are the symptoms of the first named varieties, though not nearly so Avell marked in the case of the ascaris vermicularis. Though seeming to be very plain, yet all these symptoms may be present and no worms; or Avorms present, and but feAV of these symptoms. The only certain evi- dence of Avorms is their presence in the feces, and even then Ave can not be certain, but that all have passed. The ascaris A'ermi- cularis makes itself known by an intolerable itching and craAvl- 1112 sensation about the anus. At first it generally comes on after the little patient gets Avarm in bed, the irritation being so 344 DISEASES OF CHILDREN. great that sleep is impossible; at last, they are more or less troublesome all the time. The irritation is occasionally so great as to impair the health, and occasionally gives rise to convulsions. As regards the symptoms of tape-Avorm, they are very decep- ti\7e. In one hundred cases recorded by Seeger, in sixty-eight instances nervous affections, or general or partial convulsions, roccurred—epilepsy, hysteria, abdominal spasms, convulsive cough, dyspnoea, melancholy, and hypochondriasis; in forty-two, vari- ous pains in the abdomen ; in thirty-three, disordered digestion and irregular states of the evacuatious; in thirty-one, irregular appetite and voracity ; in nineteen, habitual or periodical heini- cranias; in seventeen, sudden colic; in sixteen, sensations of undulatory movements in the abdomen up to the chest; in fifteen* vertigo, delusions of the senses, and defects of speech; and in eleven, shifting pains in various parts. The only definite evi- dence of the presence of tape-worm is the passage of portions of it with the feces, and as this usually occurs with this worm, the non-appearance of the joints in the evacuations during a consid- erable time, may be considered as good evidence that the worms do not exist in the intestinal canal. Treatment.—The treatment of the ascaris lumbricoides and trichocephalus will be very similar, the object being to remove the Avorms, and break up the predisposition to them by remov- ing the condition on which they depend. Very many vermifuge remedies have been recommended and used Avith success, so that the trouble will be, not that we have no remedies, but that we have too many. The old fashioned remedy, " pink and senna " in infusion, seemed to be about as certain as any other agent, and I am satisfied that if it were as disgusting to the Avorm as it is to the child, it would readily leave its nest in the boAvels, rather than take the dose. Still it is not more nauseous than the oil of wormseed, Avhich is an ingredient of all the principal vermifuges, as—ly Oleum Chenopodii 5x., Oleum Terebinthinae 5ij., Oleum Ricinii giij., Aqua Calcis 5x., Syrupus Limonis Saj. ; Mix ; the dose being two teaspoonfuls three or four times a day. Kuchen meister recommends the santonine, and the santonate of soda, for the ascaris lumbricoides; he considers it to be best adminis- tered in oil, in order to bring it into solution as readily as possi- ble, and thus combines it with castor oil, or sprinkles it on bread and butter, and follow it with Jalap and Senna. Troublesome intestinal worms. 345 effects sometimes follow the administration of this remedy, as severe irritation of the nervous system, convulsions, tenesmus, blooely steieds, and the minor disturbances, green or bluish vision, and discoloration of the urine. The santonate of senla he gave in doses of from tAvo to six grains on a Friday night, and the same dose on Saturday and Sunday mornings, fasting; half an hour after this last powder, confection of Senna and Jalap is taken in sufficient doses to produce several fluid evacuations, the worms passing alive, and sometimes Avandering forth Avithout any opera- tion, the intestines having become unpleasant for them. I now employ a trituration of Santonine with Podophyllin in the following proportion—Py Podophyllin gr. j. to ij., Santonine gr. x. to gr. xx., White Sugar 5ij.; triturate and make twenty poAvelers. One of these may be given morning and night, until the object is accomplished. AVhen there are no worms, but only the atonic condition of the mucous membrane with increased secretion of mucus, the patient will be benefited, and sometimes cured by the remedy. A judicious tonic course of medicine, the bowels being kept regular, and the other secretions free, with an avoidance of all grease or indigestible food, the daily use of the bath, and exercise in the open air, are the only means by which we can break up the tendency to the formation of worms. Many remedies have been recommended for the ascaris vermi- cularis, but in my opinion all vermifuge medicines should be dis- carded. If the patient's boAvels are irregular, proper means should be taken to overcome the difficulty, and if necessary a tonic and bracing treatment adopted. For the worms I have always directed an injection of salt and cold water, in the pro- portion of a teaspoonful to half a teacupful, and so far with in- variable success. Should this fail, Ave will be able to relieve the patient by the use of an aloetic purgative, as in the fedlenving formula: ly Tincture of Aloes, Compound Tincture of Lavender, aa. Sss., Simple Syrup 5j. ; a teaspoonful four times a day. Tape-Avorm is of very rare occurrence in childhood, and is possibly neArer met with during the first tAvo'or three years. The mildest treatment will be best here, and I would recommend the emulsion of pumkin seed, or the oil of male fern. The emulsion is made by depriving two ounces of the seed of their capsules, and beating them into a pulp, Avith sugar and water; this is the 346 DISEASES OF CHILDREN. dose for an adult, and is taken upon an empty stomach, in the morning; and is folloAved in from two to four hours by a full dose of castor oil. The oil of male fern is also taken, fasting, the dose being from gtt. xx. to 5j. in mucilage of milk. The most effective means for the removal of tape-worm will be found in the Pomegranate bark, according to the directions of Prof. Locke, a full description of which may be found in my Practice of Medicine. DISEASES OF THE LIVER. In the olden time, diseases of the liver Avere the most promi- nent affections of both adults and children, and Avould occupy a conspicuous place in treatises upon the subject. But as we have learned more and theorized less, the liver has played a less im- portant part in pathology, and has received less attention from the therapeutist. We have reason to believe that the intra-uterine function of the liver is of more importance than its function after birth. For, of all the organs of the body, it alone had its complete de- velopment before birth, and in size was much larger than any other organ in proportion to the body. What its functions were; there, we are as much unable to say as what its functions are in the adult; but of one thing we are convinced, that it is so admi- rably adapted to its office that it rarely suffers from serious disease. CONGESTION OF THE LIVER. AVe notice a singular disease, occurring during the first three or four months of infancy, in which there is enlargement of the right hypochondrium and the epigastrium. It is known by nurses and old ladies as liver-grown, and they propose its remo- val by rubbing Avith some fatty material—generally goose-grease That there is such enlargement there can be no doubt, and that it is relieved by these frictions is also certain, but what the exact condition is, I have never been able to determine. The symp- toms Avould indicate congestion of the liver, hence I have giv*-. if that name. CONGESTION OF THE LIVER. 347 Symptoms.—For some days the child has been fretful and uneasy, seeming to suffer from indigestion and colic. The dis- charges from the boAvels are more frequent, and have an un- healthy appearance, generally light-colored. At last the child is undoubtedly sick, has some fever, does not sleep Avell, is startled in its sleep and cries out as if in pain. It does not nurse well, and usually feels uneasy after taking the breast, and relieves itself by throwing up its milk. This has an unpleasant sour smell, and is not curded as in healthy digestion. The symptoms named may continue for some Aveeks, the child losing flesh and becoming quite feeble; and I doubt not, though I have never observed it, that this condition might continue to a fatal termination. Diagnosis.—With the symptoms above given, which resemble those of infantile dyspepsia, Ave will find a distinct enlargement of the right hypochondrium. A careful examination, with pal- pation, will sIioav the liver to be really enlarged, as its outlines can be distinctly traced. Treatment.—As named above, the treatment of the nurse is usually quite successful, and this is simply the thorough rubbing of the part with some oily material. In the hands of an olel lady, the treatment is very vigorous, with rubbing, kneading, and palpation, the child being turned from side to side, uoav on its abdomen, then on its back, and this continued for a quarter or half hour, and repeated every day, and sometimes tAvice a day. On first witnessing it I thought it pretty rough usage for a delicate and sick infant, and protested against it. But the old nurse insisted that doctors were fools, and would have her oavii Avav, and the result justified her claim to be able to treat liver- grown, for the child made a quick recovery. I learned one lesson from this, that I have put in practice many times since Avith success—that torpid organs could be stim- ulated to action by passive movements, and their circulation and nutrition decidedly improved. This is the principle of the SAve- dish "movement cure," which is claimed to be as Avell adapted to a dyspeptic stomach, as to an enfeebled limb. The remedies I would advise in this case are—ly Tinct. Bel- ladonna, Tine. Aconite, aa. gtt. iij., Avater 5iv.; one-fourth to one-half teaspoonful every hour. If it was someAvhat chronic, having lasted fen* some A\*eeks, small doses of Nux might be 348 DISEASES OF CHILDREN. given, or if there was still irritation, the tincture of Chionantbus in drop doses every three hours. If the child is feeble, and especially if suffering from a mala- rial influeuce, quinine inunction would be advisable. In all cases I Avould advise the thorough rubbing of the part, as first named. STRUMOUS ENLARGEMENT OF THE LIVER. This is not of frequent occurrence, but may be occasionally met with in the children of the poor in large cities, as the result of poor and scanty food, bad air, Avant of sunlight, want of clean- liness, proper clothing, warmth, and indeed all that we are accus- tomed to regard as the comforts of life. Rarely a case occurs in a family in good circumstances, from scrofula or bad blood, or from the depression of other sickness. Dr. Tanner observes "that a peculiar enlargement of this gland not unfrequently occurs in feeble and delicate children. The abdomen gradually enlarges, so that the little patient is said to be'pot-bellied,'and on examination one or more well defined tumors are discovered. These tumors are formeel by the enlarged liver, with perhaps an enlarged spleen; the increase in size in both cases being due to the interstitial deposit of albuminous matter. As this foreign matter is soft, and has no tendency to con- tract like the lymph poured out in ordinary inflammation, it does not much impede the passage of the blood through the liver, or the escape of bile through the ducts; and hence it very seldom gives rise to serious disturbance. Should the same material, hoAvever, become deposited in the structure of the kidneys, then the function of these glands becomes so completely interfered with that the cases cease to be amenable to treatment, and albu- minuria, ascites, and anasarca ensue, and death ultimately results." Symptoms.—The child has lost flesh in a very marked degree, though it is usually not so feeble as we should suppose by its ap- pearance. Its appetite is variable ; sometimes craving, especially for fruits, SAveets, pastry, and things it should not have ; at others it wants to eat but little. Digestion is accomplished tolerably Avell, so far as Ave can observe from any derangement of stomach or bowels, folloAving the taking of food. But it is imperfect in that the material is deteriorated during the digestive act, and can not make good blood or good tissue. ENLARGEMENT OF THE LIVER. 349 Generally, there is more or less derangement of the bowels, the discharges being too frequent, attended with uneasiness, and are light-colored. The urinary secretion is someAvhat scanty, highly colored, and sometimes presenting distinct evidence of the coloring matter of bile. The skin is generally salloAV, relaxed, and hangs in folds, the circulation being sluggish, and secretion imperfect. In the majority of cases there is slight febrile action in the after part of the day, and the child is restless and fretful at night, wanting to drink often. In some cases an unpleasant irritation of the nervous system, causing the chilel to be restless and fretful and sleeping badly, is the most unpleasant symptom. Diagnosis.—The distended abdomen, so large as compared with the general loss of flesh, and the distinct enlargement in the region of the liver, its lobes being felt as distinct tumors, is suffi- cient. In tabes mesenterica there is a somewhat similar enlarge- ment of the abdomen, but it is most prominent in the region of the umbilicus, and the nodulated glands may also be felt in the mesentery. Prognosis.—AVhen of long duration, and attended with great marasmus, the prognosis is unfavorable. But if the child has considerable strength, and digestion is not much impaired, we may expect favorable results from the use of remedies. Treatment.—I have much faith in ajudicious tonic and re- storative treatment, in all these cases, paying particular attention to the clothing, food, and that it has an abundant supply of sun- shine and fresh air. The internal administration of Collinsonia and Hamamelis al- ternated, in the doses heretofore named, will be found to quiet irritation of the bowels, check the frequency of the discharges and change their character. Associated with this, I would give the tincture of muriate of iron with glycerine morning and night. Let the child be thoroughly rubbed twice a day with the quinia inunction, freeing the surface from any surplus material by rub- bing Avith clean flannel, and occasionally by washing with soap and Avater. This I consider one of the most important parts of the treatment. The child should be clothed in flannel throughout, both winter and summer, and in chilly or cold Aveather, especial care should 350 DISEASES OF CHILDREN. be used to keep it warm, and in an atmosphere of uniform tem- perature. The room Avhere it sleeps should be thorougly venti- lated, and have a good supply of sunshine, and in addition the child should be carried in the open air. The food may be the same as recommended in cholera infinitum, -and should be carefully prepared. Sometimes more will depend upon this than upon the treatment. For a poor and bad blood ' must increase the disease, while from good food, well digested, good blood is formed, capable of supplying the tissues, and giv- ing no Avaste for struma. JAUNDICE. We have two varieties of jaundice in childhood Avhich require separate description. The first, or icterus neonatorum—the jaun- dice of infancy—is usually a very simple affection, and though of frequent occurrence, it passes aAvay Avith simple treatment. The second A'ariety resembles the jaundice of the adult, both in its pathology and symptoms, and while of rare occurrence it is sometimes a severe affection. Causes.—The causes of the first form are very obscure, and while occasionally it seems to arise from some irritation of the primce vioe, in other cases there is no apparent cause for it. The second form of jaundice may be caused by cold, produc- ing congestion of the internal organs, and especially of the por- tal circle. Or it may be produced by a malarial poison, Avhich, impairing the circulation of blood, causes congestion of the ab- dominal viscera. Pathology.—Jaundice is but a symptom of some lesion of the liver or of the blood. It consists in a change of the coloring material of the blood, and its being set free and deposited in the tissues; or more frequently in the retention and absorption of the coloring matters of the bile, and their deposit in various structures, principally the skin and conjunctiva. Occasiemally it is deposited in the deeper structures, as of the eye, giving rise to yellow vision ; in the nails, and in the internal organs. It is singular that the mildest and the severest form of jaun- dice arealike, in that they are dependent upon change in the cedoring material of the blood. In icterus neonatorum I regard the coloring matter deposited in the skin, as arising from the natural retrograde metamorphosis of the red globules, but fail- JAUNDICE. 351 ing to be removed, from some temporary inactivity of the excre- tory organs. All the symptoms point to this as the true condi- tion, for in the majority of cases, there is no lesion of the diges- tive canal or its associate organs, all their functions being car- ried on regularly and Avell; Avhile in those cases in which there is such irritation, it seems rather from arrest of excretion than from any other cause. In those extreme cases of jaundice, running a regular and very certain course to a fatal termination, the coloring material is changed hematine and not bile. In this respect it resembles the bronzed discoloration in Addison's disease (disease of the su- prarenal capsules). The other form of jaundice arises from—a, hypersecretion of bile; b, from congestion of the liver and portal system ; c, from chronic alterations of the structure of the liver, preventing se- secretion or the free discharge of bile ; d, from spasm or tempo- rary obstruction of the biliary ducts; e, from obliteration or compression of the biliary ducts or gall-bladder;/, and lastly, from disease of the duodenum, partially or entirely occluding the ductus communis. Symptoms.—Icterus neonatorum is frequently attended at first by slight febrile action. Occasionally this is quite marked, and the child is restless and uneasy, and sleeps badly, continuing fqr from one to four or five days, in a remittent fi)i*m ; it gradually passes aAvay, and the secretions being restored, the child seems as well as ever, but for the yelloAv discoloration. It will be recol- lected that in the majority of cases the fever is not high, and passes off entirely by the end' of the second day. The yelloAv discoloration very gradually fades, seeming to lie removed more by the natural removal of tissue than by special absorption. Rarely continuing less than two Aveeks, it may not be entirely remoAred for as much as three months. The other form of the disease rarely occurs during the first or even the second year. Usually, there is distention of the'bow- els, colicky pains, constipation, the'feces being clayey, pale, and scanty. The mouth is dry, has a bad taste, tongue coated, and sometimes nausea and pain in the head. The'yellow tinge usu- ally makes its appearance in the eyes, and gradually extends to all parts of the body, the color being deepest in the folds of the skin. 352 DISEASES OF CHILDREN. For practical purposes, we may divide this variety into two forms, the symptoms being distinctive and the treatment different. In the one case the patient is irritable and restless, the skin is dry and harsh, the urine high-colored, the pulse hard and in- creased in frequency, and the temperature elevated. In some cases the patient complains of pain in the right liypochondria and in the shoulders, and sometimes in the small of the back. In the second case the tongue is broad, palid, and covereel with a uniform yelloAvish white coat. The patient is dull and sluggish, and has an inclination to sleep. The boAvels are savoI- len, but not tender, the extremities cold, the skin inelastic, and the discoloration not bright, as in the preceding case, the pulse soft and oppressed. In the first form there was febrile action, in this the opposite state. Diagnosis.—The diagnosis of jaundice is easily made. The yellow discoloration is so unlike anything else met with, if Ave except Addison's disease, Avhich never occurs in childhood, that no mistake can be made. Icterus neonatorum occurs during the first feAV Aveeks of life, and may be determined by this. The pathological conditions, giving rise to jaundice proper, will be determined by the symptoms named above. Prognosis.—The prognosis of the jaundice of children is very faA-orable. While it is s'ometimes very persistent, especially the first form, there is but very little, if any danger, except from in- judicious medication. The second form yields readily to appro- priate treatment. Treatment.—For icterus neonatorum! should prescribe tinc- ture of Aconite in the usual doses, aiding it with the general bath, the general hot bath, or the hot foot-bath. When the fever de- clines I should direct that an infusion of Asclepias be gh*en in addition. It will be recollected that saffron has been the reme- dy of old Avomen and nurses for centuries, and there is no doubt but that benefit has been obtained from it. Its action was dia- phoretic. The treatment I have named restores all the secre- tions, but acts especially upon the skin. In the first variety of jaundice proper, with fever, partial ar- rest of the secretions, and with an irritation and determination to the liver, I would advise the folloAving course: Put the pa- tient upon the use of tincture of Veratrum or Aconite, the usual JAUNDICE. 353 dose's, adding Gelseminum, if there is irritation of the urinarv ap- paratus, and uneasiness in passing urine Associated with this, the tincture of Chionauthus may be given in ehws of from one to five drops every three hours, according to the age of the pa- tient. The Chionauthus is as nearly a specific for jaundice as a remedy can be for a named elisease. The patient should have the general bath and hot-foot bath, te) aid the action of the seda- tives, and the Avet pack to the right hypoehondrium, or, better, an entire abdominal pack to relieve the irritation of the liver. This plan should be followed up, Avithout addition, until the pulse has lost its frequency and hardness, and the skin is be- ceuningsoft and active, anel urinary secretion more free. If need be Ave now aeld to this a solution of acetate of potash in doses proportioned te> the age e)f the patient. A\Te Avatch its action at first, that it does not irritate the kidneys, and as it acts kindly increase its quantity. A\re observe as the febrile action passes off, anel the urinary secretion is re-established, that the eliscoloration commences te) fade. The reason is obviems, as the urine is highly charged with coloring matter, so much so as to stain the linen. Indeed, in all cases of jaundice, the coloring material is principally removed by the kielueys, and tmt, as generally thought, by the liver. In the secemd form there is an atonic condition, Avith conges- tion of the liveT, anel a failure on its part to remove the biliary material from the blood ; or, having secreted it, it is prevented from passing to its usual destination by the engorgement of the viscus, anel is re-absorbed into the circulation, and from thence depositeel in the tissues. In this case we may give mild cathar- tics, especially such remedies as act as special stimulants to the liver. Small doses of podophyllin anel leptandrin, thoroughly triturated Avith sugar, or bitartrate of potash, may be given with advantage, until they have produced the desircel effect. In place of this, small doses of Nux may be given, and the region of the liver thorough* rubbed Avith quinine and lard, or if there is marked fullness, or the patient has suffered with malarial elisease the in- unction will be Avith ointment of Uveelalia. This is fedlowed by the bitter tonics, hydrastine, quinine, or remedies of like character, and some pleasant preparation of iron. Stimulant baths Avith friction, are employed to obtain an equal circulation, anel stimulant frictions to the region of the liver, to excite it to action. 23 354 DISEASES OF CHILDREN. Having obtained these influences and restored the functions of the liver and intestinal canal, Ave have still to promote the re- moval of the coloring matter from the skin. This is accom- plished, as in the preceding case, by the use of a saline diuretic, acetate of potash or citrate of potash being preferable. PERITONITIS. Peritonitis is of rare occurrence as an idiopathic disease, both in the adult and child. As a secondary disease it may arise du- ring the progress of fevers, or from diseases of the intestinal ca- nal, and is met Avith more frequently. Usually but a comparatively small portion of the peritoneum is involved in the disease ; in some, however, a large portion is involved, and the disease is consequently very severe. Causes.—The cause of idiopathic peritonitis is most com- monly cold and arrest of secretion. In febrile diseases it is difficult to determine why a particular part is selected as the seat of the local disease, and Ave must be satisfied Avith the sim- ple knowledge of the fact. In diseases of the intestinal canal, or abdominal viscera, the peritonitis is an extension of the in- flammation of the part first diseased. AAre have still the excep- tional cases where, from perforation of the intestinal canal or stomach by ulcers, there is an escape of their contents into the peritoneal cavity, and inflammation as the result. Pathology.—In inflammation of serous membranes the ex- udation is upon the free surface, and the change of structure noticed, is from organization and change in this. The inflamma- tion is usually active in its character, and the exudation plastic. AVe have as yet no reasonable theory Avhy this extremely thin and delicate membrane, into which nerves can scarcely be traced, and which ordinarily has no sensation, becomes so exquisitely sensitive and painful. Post-mortem examination shows the peritoneum thickened and opaque, having lost its smooth and even'appearance. The lymph throAvn out is in every state of organization, from a thin film upon the surface to strong bands, which tie parts together, or agglutinate adjacent parts. In some cases there is an abundant serous fluid in the peritoneal cavity, at others more or less pus. peritonitis. 355 Symptoms.—In idiopathic peritonitis the inflammation is ush- ered in Avith a chill, followed by high febrile action. The sur- face is hot and dry, the pulse frequent, small anel hard, with much irritation of the nervous system. The countenance has an anx- ious and restless expression, and is frequently contracted as if from seA-ere pain. The thighs are flexed upon the abdomen, and the body flexed to take off the extension of the abdominal muscles. In all cases the abdomen is tense and hot, and more or less tympanitic. There is marked tenderness on pressure, even the weight of the covering producing pain in the severe cases, and slight movements elicit cries from suffering. As the disease approaches a fatal termination, the pulse be- comes very frequent, small, and thready ; the countenance is con- tracted and anxious, and the abdomen much distended, though " 7 © there is less sensibility to pressure. Diagnosis.—The diagnosis of peritonitis is made from the symptoms of acute inflammation within the abdominal cavity, Avith tenderness on pressure, and tympanitis ; at the same time the feA-er being acthTe, and the pulse frequent, and unnaturally small and hard. Prognosis.—The prognosis is not.unfavorable, except in those cases in which it is associated with some other severe lesion. Treatment.—The patient is put upon the use of Aconite or Veratrum, as the pulse is large or small, with Rhus, Bryonia, Asclepias, Viburnum, Colocynth, etc., according to special indi- cations. If the bowels are loose, Ipecac or Euphorbia are com- bined with the Aconite. If there is the expressionless mouth Avith nausea and pain simulating colic, Nux may be alternated with Aconite. The hot foot-bath may be used at first, but in severe cases it is better to use hot bricks, Avrapped in cloths wrung out of vinegar and water. When we can depend upon good nursing Ave order hot hop fomentations to the boAvels, but if Ave can not depend upon their being continuously and carefully applied, it will be better to order a mush poultice. If the pain is very seATere, and is not controlled by the means named, enemas containing opium may be employed. Five to tAventy drops of tincture of opium may be used Avith tAvo table- 356 DISEASES OF CHILDREN. spenm fuls of starch Avater or mucilage, and Avill give great relief. I think it much better than to give opium by mouth, anel Ave can not Avell resort to the hypodermic use of morphia, Avhich I prefer in this disease of the adult. HERNIA. Hernia, or rupture, in the child is of frequent occurrence, and may be through any of the natural openings in the abdominal Avail, or may be direct from the feebleness of the structures. Hernia is of more frequent occurrence in the male, the intestine passing doAvn through the inguinal canal. It is of rare occur- rence in the female through the femoral ring. Inguinal Hernia.— Inguinal hernia is of most frequent occurrence. In the majority of cases the boAvel passing through the internal abdominal ring, traverses the inguinal canal, passing through the external abdominal ring, and finally makes its Avay into the scrotum. Attention is draAvn to the child by its cries and evidence of severe suffering, and to the abdomen by its contortions, and by the loAver extremities being forcibly flexed upon it. A careful examination detects the enlargement in the inguinal region, and the hand placed upon it detects the succussion as the child cries. Direct inguinal hernia is that form in which the boAvel is forced through the abdominal Avail immediately above the external rino-, through which it may pass, anel descend into the scrotum, as in the preceding case. The distinction betAveen the tAA'o is made by tracing the course of the protrusion. In the first there is the oblique distension in the course of the inguinal canal, Avhile in the secemd the enlarge- ment ceases immediately above Poupart's ligament. Femoral Hernia.—In femoral hernia, the intestine forces its Avay under Poupart's ligament through the femoral ring, and passing up through the saphenous opening, the tumor is formed in the groin. If the hernia continues to increase, the boAA*el passes upward over Poupart's ligament, assuming very nearly the position of an inguinal hernia. The symptoms are the same as in the preceding case, and it will be diagnosed by a careful examination. hernia. 357 Umbilical Hernia.—Umbilical hernia is of more frequent occurrence in the child than in the adult. This is OAviug to im- perfect closure of the umbilicus, after the detachment of the cord, the intestine being forced through this natural opening. It varies in extent, being sometimes but slight, not larger than a good-sizeel cherry, but in other cases it may attain the size of an egg. The diagnosis is easily effected. The child suffers pain and cries severely; draAvs its feet upwards, and contorts its body as if from colic. An examination of the abdomen detects the seat and character of the injury. Treatment.— A hernia being diagnosed, the first object of treatment is to return it. This is done by the taxis—pressure being made on the boAvel in the direction that it has passed down. This pressure should be gentle, yet continued, the Avhole protru- sion being Avell supported Avith the hand, Avhile one or tAvo fingers are engaged in dislodging and carrying upwards small portions of the gut. As a general rule, but little difficulty Avill be ex- perience! in replacement, if the pressure is Avell directed. If the taxis fails from the straining or resistance of the child, it should be bmught under the influence of chloroform, Avhen pressure Avill readily reduce it. After reduction is effecteel, Ave Avill have to select an appropri- ate apparatus te) prevent the reproducement of the hernia. For. infants anel young children, I prefer a Avell fitted bandage, Avith a soft pael large enough, and thick enough to give efficient sup- port. I think in the majority of cases a radical cure will folloAV its use. In children over two years of age, the ordinary spring truss may be used. The hard pad is decidedly the best, and should be aelapted to the injury, so as to excite the part and promote adhesion. 358 DISEASES of children. CHAPTER VIII. DISEASES OF THE URINARY APPARATUS. The urinary organs of the child do not suffer so frequently from disease as do those in the adult; yet when such diseases do occur, they are quite severe and treated with difficulty. The urinary secretion removes materials from the blood Avhich are highly noxious when retained, and diseases impairing this func- tion are ahvays folloAved by marked constitutional disturbance. ACUTE NEPHRITIS. Acute inflammation of the kidneys may be produced by cold, or may arise from other causes of inflammation, but in the ma- jority of cases it arises during the progress of eruptive fevers, especially scarlatina; and is doubtless dependent on some action of the fever poison, with which Ave are unacquainted. It is pos- sible that the arrest of secretion from the skin in these cases throAvs an additional amount of work upon the kidneys, from the irritation of Avhich the inflammation arises. Symptoms.—Inflammation of the kidneys is announced by increased excitement of the nervous system, and an increase in all the febrile symptoms, if it occurs during the progress of an- other disease The child passes urine frequently, but in very small quantity, anel seems to suffer much at these times. In some cases the urine Avill be tinged with blood, sufficient to discolor the diaper. The pain and uneasiness are attended Avith contortions of the body, flexure of the limbs, and straining, so that it may be easily mistaken fe)r colic. These symptoms, as Avell as the duration of the period of excite- ment, Avill vary as one or both kidneys are involved in the in- flammation. In the first case they will not be so severe, and may last two or three days, or even more; but in the second thcv Avill not last longer than twenty-four hours. Occasionally con- vulsions ensue early in the disease. ACETE NEPHRITIS. 359 The secoml stage of an inflammation of the kidneys is that in which, from retention of urea, the nervous system is depressed, ami coma results. A very short time is necessary for this change of symptoms (tAvo to four hours) ; the nervous irritation passing off, the patient becoming dull, drowsy and comatose; this gradu- ally deepening until the patient dies. In the first stage the pulse is frequent and hard, the skin dry and harsh, the mouth anel tongue dry, and the temperature quite high. In the second stage the pulse becomes small, its frequency still more increaseel, but it*loses its hardness, the temperature of the surface is diminished, and the extremities become cold, yet the thermometer sIioavs a higher temperature than before. In the severe cases the duration of the disease will not be more than from tAvo to four days, unless the patient is relieved. In mild cases it may continue a Aveek or more. Diagnosis.—The increased nervous excitement will attract our attention, and cause us to make a very close examination. The pain that the chilel suffers is undoubtedly in the abdomen, and would be mistaken for colic, Avere it not that it comes on in passing urine, and is very closely associated with this. The scanty urine, tinged with blood, passed a few drops at a time, and with straining and pain as named, is the most striking diag- nostic feature. Prognosis.—The prognosis is not favorable when both kid- neys are involved, unless the lesion is noticed early and prompt treatment is adopted. AVhen but one is involved Ave expect a favorable termination. The prognosis is of course more favora- ble in the stage of excitement, than in that of depression and coma. Treatment.—In the first stage of the disease the child is put uimn the use of Veratrum and Gelseminum in full doses, the ob- ject being to arrest the fever and inflammation at once. I think there are no remedies that will take the place of these, at least there are none that I would like to trust. I would give them in the following proportion : R Tincture of Veratrum gtt. v., Tincture of Gelseminum gtt. x., water, 5iv. The nurse is directed to give a teaspoonful every hour, until she observes an abatement of the fever, then reduce the dose one-half and continue. 360 DISEASES OF CHILDREN. In place of Gelseminum avc sometimes employ Macrotys, as there is muscular pain or soreness, or Cannabis Indica, there being irritation of the urinary passages, even to the meatus urinanus. Bryonia is sometimes a good remedy if there is marked contrac- tion of the abdominal muscles; Belladonna if there is fullness of the abdomen with stupor and disposition to sleep, or if there has been retrocession of an eruption. Eryngium is a good remedy when there is a constant desire to pass urine ; Apocynum when the eye- lids are SAvolleu and the feet (Edematous, or the slightest evi- dence of dropsy. Cathartics are absolutely contra-indicated, as are diuretics, and diaphoretics are of no value until Ave have first obtained the in- fluence of the remedies named. As a local application I like the influence of the hot hop fomentation better than anything else. I order the application across the loins, the child lying upon the abdomen, but Avhen tired in this position it is placed upon its back, and the fomenta- tion applied over the loAver part of the abdomen. The child should always be kept in bed, between blankets, and the action of the skin may be solicited by the use of hot bricks near the feet, Avrapped in Avet cloths. This treatment is persisted in until the febrile action is par- tially checked, and secretion of urine is increased, the patient meanwhile being allowed as much fluid as desired, unless it causes nausea. As soon as Ave have the patient fairly under the influence of the sedatives, avc commence the administration of the milder vegetable diuretics, as haircap moss or mentha viridis, and continue them until the secretion is wholly restored. In the second stage of the disease the patient is suffering from uraemi'cpoisoning, and the treatment Avill be Avholly different. AA'e give at once a brisk cathartic, as of jalap and bitartrate of potash, and if the case is one of emergency, Ave may aid its action by a cathartic enema. Dry cups are applied to the neck and over the loins, and a hot stimulant application over the kidneys folloAvs their use. Stim- ulants and heat are also applied to the extremities. The internal remedy that I rely upon with most confidence is Belladonna, which may be given in the fedlowing proportions : R> Tincture of Belladonna gtt. v., Tincture of Aconite gtt. v ., AA-ater Siv.; a teaspoonful every hour. If the reader can ne>t make up his mind to the use of such small doses in such a grave CHRONIC NEPHRITIS. 361 affection, I would advise in its place a prompt and very thorough emetic, followed by the cathartic as first named. In the use of diuretics we Avill have to be very careful as the patient convalesces, fen- the kidneys are in a very irritable condi- tion, and a slight irritant is sufficient to arrest the flow of urine. It is fortunate that the tincture of muriate of iron, in quite small doses, is a good tonic to the kidneys, as it is the restorathTe Ave most frequently employ. / CHRONIC NEPHRITIS. Chronic nephritis is never met Avith during the first year, is very rare during the second, but is occasionally met with from this up to the sixth ye-ar. After this time it is hardly ever seen until the person has reached middle life. It is a very insidious elisease, coming on slowly, anel presents so feAV prominent symp- toms that in many cases it is not detected. Causes.—The causes of chronic nephritis are very obscure. It may arise from colel, from irritant diuretics, but probably is most frequently the result of some morbid condition of the blood, or change in the process of retrograde metamorphosis. AVe know the irritant effect that the presence of the urates, triple phosphates and oxalates have on the bladder, and Ave can Avell imagine that their excretion by the kidneys may set up a sIoav process of in- flammation in these organs. Pathology.—The inflammation may be confined to one, or may affect both organs, or it may involve but the cortical struc- ture of the kidney, the tubular remaining comparatively free. Post-mortem examination shows the kidneys enlarged, Avith evidences ofenfeebled circulation. The structure is softened and friable, anel the capsule readily detached. In some cases there is a free deposit of a Avhite amorphous material. In others the inflammation has progressed to suppuration, and more or less of the structure has been destroyed by it. Symptoms.—The chihl has lost flesh and strength, in a marked degree ; its appetite is impaired, digestion feeble, the boAvels irreg- ular and the skin dry and harsh. Irritability and restlessness is a marked feature, and is sometimes developed to that extent that the child becomes a burden to itself and all around it. 362 DISEASES of children. If old enough to locate its sufferings it will complain of pain in the back and across the loAver part of the abdomen. Occasion- ally it experiences uneasiness before urinating, and sometimes after its discharge. Frequently, however, no complaint of this kind is made, anel though the child undoubtedly suffers uneasi- ness and pain, it is of such a fugitive character that he can not locate it. These symptoms are constant, anel gradually increase, but in addition there are exacerbations in the disease, coming on at in- tervals of tAvo or three Aveeks. At these times the patient suffers from fever, the skin is dry and hot, the urine very scanty, the boAvels constipated, Avhile the face has a pinched and anxious ex- pression. It is evident at these times that the child suffers from pain in the backhand frequently the lameness is quite marked. Thus the disease progresses, until finally the periodic exacer- bation of the inflammation is much worse The fever is active, with great excitation of the nervous system, occasionally with convulsions. The urinary secretion being arrested, the symp- toms of uraemia are rapidly developed, and within tAventy-four hours the patient is comatose, and by another day it terminates fatally. Diagnosis.—The diagnosis is principally made by exclusion. The examination is made with reference to disease of special parts, as of the brain, lungs, digestive apparatus, etc. One after another being excluded, Ave finally trace the diseased action to the kidneys, and the symptoms given above Avill be found suffi- cient to designate the character of the disease. Prognosis.—The prognosis is favorable in the early stage of the disease; but Avhen it has continued for some months, having lost flesh to a great degree, with frequent pulse, harsh dry skin, scanty high-colored urine, great irritability of the nervous system, with a pinched and anxious expression of countenance, the prog- nosis is doubtful. Treatment.—The treatment of this case is one of much diffi- culty, and Avill have to be varied from that Ave would use in the adult. As a general rule, I should give but feAV medicines, in- deed experience Avill teach that the stomach Avill not tolerate much, and that all irritants are injurious. albuminuria. 363 Small doses of Aconite with Gelseminum, Rhus, Bryonia, Apocynum, Eryngium, Cannabis Indica, or Agrimonia, as indi- cated, Avill serve the purpose Avell. Apocynum should be espe- cially noted as the remedy if there is the slightest evidence of oedema. Agrimonia is indicated by the pain Avhich sometimes extends up into the hypochondria. If the chilel is nervous and cries at every little thing with sobbing, small doses of Pulsatilla may be alternated Avith the other remedies. The child may have a hot salt-Avater bath every day, being1 rubbed Avith dry flannels afterward and clothed warm. Or, in place of this, Ave may use fatty inunction, rubbing the surface thoroughly. Inunction Avith quinine ansAvers an excellent pur- pose in some cases, especially those in Avhich there is a malarial influence. The best lcoal application for the child is the vinegar pack, applied upon going to bed. A flannel cloth, six inches Aviele, is Avrung out of tepid vinegar, and applied around the body at the loins, and this is again covered by a dry strip; it is removed on getting up, and the part thoroughly rubbed with flannel. As the severer symptoms pass away, the patient may have some of the tonic and astringent diuretics, if thought best, or it may be continued upon the remedies already named, at less fre- quent intervals. The compound syrup of the hypophosphites, some of the preparations of malt, occasionally iron, Collinsonia, Hydrangea, or Eryngium, or the quinine inunction, may be con- tinued to complete recovery. ALBUMINURIA. AVhile albuminuria in the child is most frequently the sequel of the eruptive fevers, it is occasionally seen from other causes. It is not dependent, however, on granular degeneration, or Bright's elisease, in either of these cases, and is, therefore, a much less grave affection. Pathology.—It has been supposed that the albuminuria fol- lowing the eruptive fevers Avas dependent upon irritation, or a low grade e)f inflammation of the kidneys. AArhile this may be the cause, to a certain extent, Ave haA-e reason to believe that the changes effected in the blood by the febrile poison is an im- portant element of the disease. 364 DISEASES of children. Post-mortem examination shows the kidneys swedlen, the glomeruli congested, and the tubuli uriniferi more or less loaded with albuminoid matter. Casts from the tubules may be de- tected in the urine during the progress of the disease. Symptoms.—Occurring almost ahvays after the eruptive fevers, on exposure to cold, by Avhich the surface is suddenly chilled, it commences generally Avith a Avell-defined chill; symptomatic fever follows, the pulse being hard and frequent, the skin hot, dry, and constricted, the tongue coated white, the mouth dry, frequently nausea and vomiting, bowels constipated, pain in the back, and marked restlessness and nervous irritation. With these symptoms the patient complains of a sense of Aveight and constriction in the region of the kidneys, neA'er, as is said, ex- tending to or causing retraction of the testicles. The pain may be confined to one side, but one kidney being affected, or it may be equally in both sides. AVith the occurrence of these symptoms the urine becomes scant, almost suppressed, and highly albuminous, of a reddish color, and occasionally bloody. Its specific gravity is almost always above that of healthy urine, and it gives an acid reaction. When alloAved to rest, it deposits a filamentous substance, and when examined with the microscope it will present blood-glo- bules, mucus, epithelium, and in some cases complete casts of the urinary tubules. A dirty-white sediment is frequently depos- ited from the urine, not unlike mucus, and easily diffused by agitation. The urine is frequently passed Avith difficulty, and sometimes with pain, the calls to urinate being frequent and dis- tressing. In the course of the second or third day dropsical symptoms make their appearance, most frequently as anasarca of the eye- lids, face, and at last of the Avhole body. The skin at this time is hot, and does not pit except upon firm pressure. If properly treated, in a majority of cases, Ave find that the symptoms are much mitigated in the first three or four days, and the disease terminates in recovery by the tAvelfth to the fifteenth day. In other cases coma comes on by the second, third, or fourth day, and the disease terminates fatally within the first Aveek. Occa- sionally convulsions appear, and continue until the patient is exhausted. In other cases the disease seems to give way slowly, until it reaches the chronic stage, in which it continues. DIABETES. 365 Treatment.—If the temperature is above the normal stan- darel and the pulse is too frequent, Ave give Aconite with Apocy- num (gtt. iij., gtt. v. to gtt. x., Avater §iv.) In some case-, fol- hnving the eruptive fevers, there has been something omitted fre>m the treatment of the cases, and Ave endeavor to find it. It is possibly Belladonna, Rhus, Apis, Phytolacca, or Macrotys, but Avhatever it is, it shoulel uoav be given if the indications still persist. In some cases the hydragogue cathartic, like jalap with bitar- trate pf potash, is employed, to increase secretion by Avay of the bowels, and remoA-e dropsical accumulations, but I prefer the more direct remedies, Apocynum anel Aralia Hispida. If the dropsy is not reached by these remedies, Ave Avill some- times find the small eh) e of sulphate of mangr Aese a good rem- edy. It may be given in the folloAving proportion: R/ Sulphate of manganese gr. \T., Avhite sugar oj.; make twenty powders, and give one every three hours until it acts upon the boAvels. The hot foot bath may be used, and dry cups, followed by hot fomentations, applied to fhe loins. If the case seems to be ur- gent, Ave may use the general hot-bath with advantage, continued for one or two hours, the surface being rubbed dry, and the child clothed or Avrapped in flannel. In some cases quinine inunction ansAvers an excellent purpose, but sometimes the fatty matter seems to close the skin, and Ave are obliged to have the child thoroughly Avashed Avith soap and AA'ater to remove it. In other cases the inactivity of the skin is relieved by a sponge bath of Ilydrochlorate of ammonia and water. DIABETES. I have never seen bnt one case of diabetes in children giving the evidence of sugar on analysis, and this was in quite small quantity, and for a short time ; neither do I recollect seeing any such eases recorded. Diabetes insipidus, on the contrary, is met with quite as frequently in childhood as in the adult, and is some tjmes very persistent. Causes.—The causes giving rise to this increaseel flow of urine are vcrv obscure In some cases the exciting cause seems te) be cold, but more frequently it will be found to be dependent upon, or at least associated with some disease of the nervous centers. 366 DISEASES of children. Pathology.—I think, in all of these cases, there is an impair- ment of circulation, Avith tendency to congestion. The nervous system suffers first, and the enfeebled innervation seems to be one cause of the lesion of the kidneys. The conelition of the kid- neys seems to be one of atony rather than excitation—one which permits the Avater of the blood to filter off, rather than increaseel activity of secretion. Indeed, in some cases, the patient suffers first the nervous irritation from retained urea, and aftenvard from uraemic coma. Occasionally there is the same profluvia from the boAvels, but in less degree. Symptoms.—It will haA-e been noticed that the child has lost flesh rapidly for two or three weeks, or may be, for as many months, and that it is becoming quite feeble; yet it has a pretty good appetite, and digestion is well performed, and the chilel eloes not complain of any particular suffering. If associated Avith diarrhoea, the loss of flesh and strength will be attributed to this. AVhen Ave examine the patient, Ave find the pulse feeble, small, and soft, and somewhat increased in frequency; the surface is pale, cool, and Avanting in tone, and the child suffers from colel feet and feeble circulation. The tongue and mucous membranes are pallid, but the tongue is not coated. Usually there are two, three, or four fluid movements from the boAvels daily, but they are not large or unhealthy. Upon close inquiry, Ave Avill learn that the child passes Avater frequently at night, and the bedding is very Avet, and when the mother's attention is called to it, she will notice the frequent passage of large quantities of clear urine. If Ave examine a portion of the urine we will find it limpid, very light-colored, and of low specific gravity, frequently not more than 1008. I have seen cases, in Avhich the child Avould urinate on an average every fifteen minutes during the day, and every half hour at night. In the severer cases the marasmus is as great as in the diabetes mellitus of the adult. In such cases the irritation of the nervous system is extreme, and the child suffers intensely from nervous excitement. In some cases it seems almost impossible for it to obtain sleep. Continuing on in this way for a short time, this is replaced by coma, and a feAV hours will terminate its life. Diagnosis.—The diagnosis of diabetes of the child will be easily made, if our attention is directed to the kidneys as the seat DIABETES. 367 of disease. This is the advantage of forming a habit to correct the diagnosis of every case by exclusion; as each organ is thus passed under revieAV, it is almost impossible to fall into serious error. • The frequent and abundant discharge of urine may have escaped notice until attentiem is drawn to it, or the mother may have considered it an unimportant circumstance. Prognosis.—The prognosis is favorable in the majority of cases, as the disease yields readily to remedies. AVhen-it has continued for a considerable time, the child being wasted almost to a skeleton, the nervous system being very irritable, the prog- nosis is unfavorable. Treatment.—In the milder cases, the treatment is very sim- ple and direct. The child is put upon the use of—Py Tincture of Belladonna gtt. v., Avater §iv.; a teaspoonful every two hours. To restore the action of the skin, and at the same time, get its action as a tonic, I employ the quinine inunction once daily. When there is atony of the digestive apparatus, and torpor of the liver, minute doses of podophyllin may be given. The following combination Avill ansAver well: ly Podophyllin gr. j., Hydrastine gr. v., white sugar gr. xx.; tritutate thoroughly and divide in twenty parts; one may be given in the morning and one at night. In some cases Ave may alternate the Belladonna with Hama- melis (Pond's extract), in doses of ten drops, giving each every four hours; and when diarrhoea accompanies it, this may be con- trolled with Ipecac. As the disease is brought under the control of remedies, we may alternate them with the Collinsonia, tincture of phosphorus, Rhus Aromatica, and the tincture of muriate of iron, as a restor- ative. But if the patient gets along well, we will, in the major- ity of cases, find no cause for change. ISCHURIA. Ischuria, or arrested discharge of urine, is divided into two varieties—ischuria renalis, suppression of urine, and ischuria vesicalis, retention of urine. Both of these should be regarded as but symptoms, as they may arise from various and Avidely differ- ent causes. 368 DISEASES OF CHILDREN. Suppression of Urine.—Suppression of urine may be the re- sult of an active inflammation of the kielueys, as Ave have already seen. But the cases that will come under our notice most fre- quently, depend upon exhaustion or enfeebled innervation of the kidney, or from congestion.' It occurs most frequently during the progress of acute disease, especially in such as are atteneled with serious blood-poisoning. Symptoms.—The symptoms of suppression of urine vary in different cases. AVhere the suppression is partial, as is generally the case, Ave find the first evielence in great excitation of the nervous system, and an increase of the febrile symptoms. Not unfrequently, Ave Avill find the desire to pass urine increaseel, anel the frequency of the effort, but sm".ll quantities passing, will first attract the attention. As it continues, the symptoms of the uraemic coma begin to be developed, the chilel is dull, has a tendency to sleep with its eyes partly open, and starts frequently from its sleep as if alarmed. Occasionally convulsions precede the coma, Avhich seem to be dependent upon it? Nausea and vomiting occasionally occur in the early part of the disease, and the irritability of the stomach is one of its most troublesome features. From the commencement of coma, Ave find it becoming deeper as time passes, until at last it is impossible to arouse the patient. The pulse is feeble anel irregular, the ex- tremities cold, the features contracted and pinched, with occa- sionally more or less convulsive movement, until death ensues. Retention of Urine.—Retention of urine is most frequently due to paralysis of the bladder, though it may be produced by irritation of and contraction of the neck of the bladder or urethra, or in some rare cases, it is dependent upon the presence of a calculus. Retention from exhaustion of the muscular coat is of common occurrence in low forms of disease, anel is sometimes a source of much trouble. Retention from irritation of the urethra is attended with much pain, and a frequent desire to pass water. Symptoms.—In retention of urine occurring during the pro- gress of low forms of fever and iinflammation, it will be noticed that the prostration is much greater, and the symptoms more ISCHURIA. 369 grave, than would haATc been anticipated in the ordinary pro- gress of the disease. Frequently the attention is drawn to the difficulty by the marked uneasiness of the child, and the move- ment of the hands to the region of the bladder. In retention frenn contraction of the neck of the bladder or urethra, there is the evident desire te> pass urine, attended with straining and pain, out the want of power to overcome the ob- struction. Diagnosis.—Having learned that the urine has not been passed, Ave have to determine Avhether it is a suppression or re- tention. This may be determined in many cases, by the symp- toms above elescribeel, or by an examination of the bladder with the hand. If this is not satisfactory, a catheter may be intro- duced into the bladder. This, however, is attended with diffi- culty, anel may generally be dispensed with. Treatment.—In the treatment e>f suppression of urine in the child, I rely more upon the use of hot fomentations across the loins, than on any other means. They should be assiduously employed, anel continued until the desired result is produced. If the patient has fever, Tinct. Areratrum gtt. iij., Tinct. Gel- seminum gtt. x., Avater oiv., a teaspoonful every hour, '-will be good treatment. If the face is pinched and the patient is rest- less, starting in sleep, Rhus may be gh-en Avith Aconite. If the patient is dull anel Avants to sleep most of the time, Belladonna Avill be suggested. Apocynum answers an excellent purpeise, if there is a puffy condition e>f the eye-lids, or s\Arollen feet. To relieve the system from the symptoms of uraemic poisoning, a cathartic may sometimes be given, if there are no circumstances to contra-indicate it; jalap and bitartrate of potash Avill ansAver this purpose very well. As soon as urine commences to pass in small quantities, diure- tics may be administered, the remedy being selected to meet the condition of the patient, being demulcent, stimulant, or tonic, as the case may require. In some cases, dry cups may precede the use of the hot fomentations, and Avill be found of much service. In the treatment of retention of urine in children, I prefer the use of santonine to any other remedy I have employed. I have used it in eloscs of from one-fourth to one grain, triturated with su^ar, repeated every two hours. This may be assisted by hot 24 370 DISEASES OF CHILDREN. fomentations applied over the bladder and genitals, or in some cases by a hot sitz bath. The use of diuretics is contra-indicated in this case, as they rather diminish than increase the power of the bladder to evacu- ate urine, while they certainly increase the distension. AVhen the retention is dependent upon stricture of the urethra, or contraction from irritation, Ave will obtain the best results from an enema of equal parts of Lobelia and Gelseminum 5ss to Avater 5j. ENURESIS. Incontinence of urine is most commonly a disease of child- hood, though Ave occasionally meet with it in the adult, but usually as the result of injury, or from disease. In the chilel it varies from the slight form of nocturnal incontinence, to the severer cases in which the patient is wholly unable to retain the urine, and it flows aAvay all the time. Causes.—The causes of incontinence are someAvhat obscure. In some of the milder cases it seems to be a habit more than a disease. The severer cases folloAV the eruptive fevers, diseases of the nervous system, and occasionally diseases of the urinary ap- paratus. Pathology.—In some cases the incontinence is dependent upon an irritable condition of the mucous membrane of the bladder, slight distension of the viscus giving rise to involuntary muscular contractions and expulsion of urine. In other cases the muscular fiber is in an irritable condition, and contracts from slight excitement. In other cases, and by far the most numerous ones, the lesion is of the nervous system. In one it is of the spinal system, an atonic or feeble condition, and as the result of this, there is imperfect contraction of the circular fibers at the neck of the bladder, and the first portion of the urethra, which serves the purpose of a sphincter. In the other it depends upon irritation of the lumbar spine, with involuntary contraction of the bladder from the disordered innervation. Symptoms.—The simplest form of the disease is that in Avhich the child wets the bed. Frequently, in these cases, the child drinks freely in the evening, and the bladder being distended at ENURESIS. 371 night, the urine is passed unconsciously, or under the influence of a dream. This may continue to the age of puberty, or even longer, becoming a source of very great annoyance and mortifi- cation. In other cases there is not only the nocturnal incontinence, but there is a frequent desire to eA'acuate the bladder through the day, and if not promptly attended to, involuntary passage of urine occurs. Then there is the severe form of the disease, in Avhich the person has no command over the passage of urine, but it dribbles aAvay continually, keeping the clothes soiled, and making it quite impossible to keep the chilel free from a disgusting urinous odor, irritating the surface about the parts, and requiring much care to prevent its suffering from cutaneous irritation. Treatment.—In the simpler forms of nocturnal incontinence, it is frequently sufficient to prevent the child's drinking in the evening, see that it passes urine before going to bed, and have it waked once in the night for the same purpose. AVhat Ave want is to break up the habit of involuntary passage, and this may be done in the majority of cases in this way. In this, and other forms of the disease, when there is no special lesion, I rely upon the Belladonna as a specific. I usually pre- scribe it in the following proportions. Py Tincture of Bella- donna gtt. x., water §iv.; a teaspoonful three times a day. In se- vere cases, those dependent upon atony of the spinal cord, or consequent Avant of contraction of the sphincter fibres, the Bella- donna is our best remedy, anel will give relief when the person has been supposed incurable. Ergot has a very similar influ- ence, and may sometimes be alternated with it. I Avould use it in the proportion of—Py Tincture of Ergot gtt. xx., water 5'iv.; a teaspoonful four times a day. The Rhus Aromatica has been highly recomended in these cases, and may be tried, though thus far I have not seen the marked results that have been described. In feeble children the syrup of iodide of iron has been given Avith advantage in doses of five or ten drops three times a day. Irritability of the bladdder should be treated by the use of Agrimonia, Hydrangea, or Collinsonia, combined with a tonic anel restorative treatment, as it is usually associated Avith impaired health. A Belladonna plaster applied over the bladder Avill give 372 DISEASES OF CHILDREN. present relief, but its continued use Avill sometimes produce un- pleasant symptoms. Frictions over the bladder with the lini- ment of Stillingia will answer a better purpose. In those rare cases in which the incontinence is epileptic in its character, I Avould advise the bromide of ammonium alternated Avith Bellademna. URINARY CALCULI. Stone in the bladder is met with even during the first year of life, and from this up to adult age. It is not of as frequent occurrence in the child as in the adult, yet it is met with more frequently than many suppose. There is no doubt but that many children suffer for months, and finally lose their lives, without the detection of the lesion. Previous to the last quarter of a century Ave find but feAV cases of stone in the bladder of children recorded, and the cases of cutting for stone in children under six could be Counted upon the fingers. In the last feAV years a large number of cases have been reported, Avith successful operations for their relief. One surgeon alone reports some thirty cases in ten years. AAre must, therefore, conclude that the disease Avas not recognized, as it is not probably of nmre frequent occurrence iioav than in the centuries past. KnoAving these facts, Ave Avill notalloAV ourselves to make the same error in diagnosis. If stone in the bladder in the child Avas incurable, this error in diagnosis Avould make less difference; but the experience of some of the most skillful surgeons sIioavs that the operation for its removal is much more successful than in the adult or ageei. Pathology.—Urinary calculi may result from lesions of di- gestion, but mostly from lesions in the Avaste of tissue and retro- grade metamorphosis. All are composed of the normal elements of tissue, except in those rare cases in Avhich the material is furnished by maldigestion. The urinary organs do not seem at all at fault, indeed they perform the additional function of re- moving a material from the blood which would prove injurious there. The calculous formations in childhood are principally of three kinds—uric acid and urates, oxalates, and phosphates. These may be deposited in the form of minute crystals, being washed URINARY CALCULI. 373 from the bladder by the flow of urine, giving rise to no lesion but irritation of the bladder and urethra; or they may accumu- late anel coalesce to form those masses of variable size, Avhich Ave knoAV as calculi. The uric or lithic calculus is of a broAvnish mahogany color, oval or flattened in fi>rm, and finely tuberculated or smooth, themgh not polished. It is perfectly dissolved in caustic potash, anel disappears with effervescence in hot nitric aciel, the solution affording, Avhen evaporated to dryness, a bright carmine residue. It bee'omes black and is gradually consumed befe)re the blow-pipe, leaving a minute quantity of white alkaline ashes. Oxalic calculi are generally of a dark broAvn color, rough and tuberculated, hard, compact and imperfectly laminated. It is insoluble in the alkalies, dissolves slowly in nitric and hydro- chloric acids, if previously Avell broken up, ami under the bloAV- pipe, expands anel effloresces into a white poAvder. Phosphalic calculi are e>f a lighter color, less clear anel friable. Phosphate of lime more frequently forms layers with other mat- ter; Avhen it occurs alone, they are usually small, of a pale brown color, of a loosely laminated structure, not fusible with the blow- pipe, but readily soluble in hydrochloric acid with effervescence The amoniaco-maguesian calculus is of a Avhite color and friable, looking a good deal like a mass of chalk. It exhales an ammo- niacal odor before the blow pipe, is not affected with caustic potash, but is easily dissolved in dilute acids. There is a form of phosphatic calculi that is fusible. It is Avhite, extremely brittle, easily separated into layers, anel leaves a Avhite dust on the fingers. It is not affected by caustic potash, is soluble in hydrochloric acid, and is melted into a transparent pearly glass under the bloAV-pipe, Symptoms.—The general symptoms attending the presence of urinary calculi in the child are pretty Avell marked. The appe- tite is irregular, digestion is impaired, and frequently there are Avell marked dyspeptic symptoms. The secretions are deranged, the skin being very susceptible to external impressions, at times dry and harsh, at others soft, relaxed and flabby, Avith cold ex- tremities. The boAvels are torpid and sluggish in most cases, but in some the irritation of the bladder extends to the boAvels, and there are frequent discharges. The patient is irritable and fret- ful, and extremely restless, and dissatisfied with everything done for it. 374 DISEASES OF CHILDREN. The local symptoms are sometimes very marked, in other cases the patient Avill have to be observed fe>r some time before Ave have such evidence as will lead us to make the necessary exam- ination. There is some difficulty in passing Avater, but it is not constant, as at one time the urine may be evacuated Avithout any trouble ; at another time the urine Avill be stopped in its passage, with more or less pain and tenesmus. Occasionally at such times the urine will be stained with blood. As the case advances the difficulty in passing urine becomes more frequent, and is attendeel with greater suffering. The patient suffers from sense of Aveight and pain in the bladder, loins, and small of the back, sometimes so severely that the countenance presents that peculiar contracted anxious expression, Avhich Ave observe in long-continued painful diseases. Progressing in this Avay the chilel becomes exhausted from the long continuance of suffering, and the functional derangements that fedloAV it, and Avill succumb to this, or to some local disease of the pelvic \Tiscera induced by the calculus. Diagnosis.—The uneasy sensations in the bladder, with diffi- culty in passing urine, point to the bladder as the seat of disease, Avhile the long duration e>f it and its intractability Avould lead us to suspect the presense of a calculus. To determine this a sounel is introduced into the bladder, and careful manipulation will detect its presence. Prognosis.—The prognosis may be regarded as favorable, Avhether Ave conclude to practice lithotrity or lithotomy—both these operations being successful in the you no-. Treatment.—Having determined upon an operation Ave prepare the patient for it as best we may, in the short time Ave have. I think it of advantage to keep the patient very still for a feAV days, giving small doses of Aconite anel Gelseminum, Avith some demulcent diuretic to relieve the irritation of the bladder. In some cases much relief will be obtained if the child lies upon its abdomen a portion of the time, as it removes the pressure from the base of the bladder. In the meanwhile Ave see that the stomach is placed in condi- tion to take and digest some food; and Ave may use the tincture imperforate urethra. 375 of muriate of iron and glycerine as a restorative. Quinine in- unctions will prove beneficial in some cases, giving strength to the nervous system. Lithotrity is preferred by many surgeons at the present time, as giving good results, notAvithstanding the smallness of the urethra. The calculi of children are generally more friable than in the adult, and are much easier crushed, and the urethra may be dilated so as to admit a good sized instrument. Lithotomy is performed in the usual Avay, the Icderal operation being preferred. Though it is not prudent to make the large incision permitted in the adult, but with a little care in its dila- tion with the finger, and in seizing the stone so as to present its smallest diameter, there will be no trouble in its extraction. The principal points in the after treatment are to keep the patient quiet, keep down the febrile action, and the stomach in condition to receive fooel. When the child has recovered from the operation, it should be put upon such a course of treatment as Avas named for dyscrasias. In addition to this tonic and alterative plan, it may be possi- ble to employ special means to antidote the tendency to calcu- lous formations. The information necessary for this will be found in my Avork on Practice, pp. 357 to 366 IMPERFORATE URETHRA. Rarely a case of imperforate urethra will be met Avith in the new-born chilel. The malformation will be brought to the phy- sician's notice by the child not passing urine, and suffering pain in consequence of it. An examination Avill determine the char- acter of the lesion. In other cases the urethra terminates by false openings in the upper or under surface of the penis—hypospadias and epispadias. These are rarely more than one inch from the meatus, frequently not more than half an inch. Treatment.—In imperforate urethra the difficulty may be remedied by passing a large exploring needle, or small trocar, through the meatus and carrying it upAvarel until it reaches the free portion e)f the canal. A silver catheter being now intro- duced it is Avorn until the part heals. In hypospadias, and epispadias, though there is no danger to 376 DISEASES OF CHILDREN. life, I think that the malformation shoulel be remedied in infancy, as it can be best done at this time and with the least danger. Open up the canal of the urethra in the manner above named, and passing a catheter, retain it for the urine to pass through. Then freshen the edges of the artificial opening, and draAV them together with a silver suture. If, as in some cases, the canal really terminates with the false opening, I would operate by de- taching the skin at that part, if m>t too far up, bring it down to the glans and attach it with silver ligatures, retaining a catheter until the part had healed. P II Y M 0 S I S . The natural conelition of the penis in the child is, with the elongated and contracted foreskin entirely covering the glans. It is only in exceptional cases that this is a source of trouble. In one of these cases an inflammation of the prepuce and glans is set up, and there is a free discharge of pus. Sometimes the inflammation runs high, and the prepuce is so SAvolleu as to render the passage of urine very difficult and painful. This is really a case of infantile balanitis, and being difficult of cure, or recurring frequently, it may require removal of the prepuce. In the other case, the prepuce being quite long and much con- tracted, is irritated and inflamed by the urine, so as to be a source of very great annoyance I have seen tAvo cases in Avhich this Avas a source of serious disease, and there Avas but the one way for its removal, and that by removal of the prepuce. Treatment.—Circumcision is very readily performed in the child, and is not attended with any danger. The method I Avould recommend is to take the foreskin betAveen the thumb and finger for half an inch, then draAving it doAvn Avell to clear the glans penis, excise it with a bistoury, cutting toAvard the finger. But if afraid that you may Avouud the glans, draw down the pre- puce with the fingers, and have an assistant grasp it next the glans with a pair of dressing forceps, or the arms of a pair of scissors, then cut betAveen the fingers and it. Retract the foreskin anel apply a Avater dressing until the part heals. Some may make objection to circumcision, as Avas once the case in my practice. The mother declared she Avould not have her child made a JeAV of, even though the penis had to be cut off. In this case, simple incision of the prepuce on a grooved director, URETHRITIS 377 its entire length, retracting it over the glans, and retaining it with adhesive straps, Avas all that Avas required. PARAPHYMOSIS. Paraphymosis is the retraction of a tight prepuce above the glans penis It is occasionally met with in boys of from six to ten years, Avho have, out of curiosity, or prompted by those older, pushed the foreskin back anel have not been able to return it. The glans becomes SAvolleu and painful, and if the constric- tion continues long it may go on to inflammation and finally to sloughing. In many cases the application of cold Avater or ice for a short time Avill reduce the swelling anel permit the foreskin to be draAvn down. It is also claimed that if a couple of hairpins are used, pressing the bent end up under the prepuce on each side of the glans, the prepuce can be draAvn down over them. If this does not succeed, or if so long a time has alreaely elapsed that Ave do not think it prudent to try these means, we Avill incise the pre- puce and thus free it. This is easily accomplished by passing a grooved director under the foreskin on the dorsum of the penis, and cutting outward with a sharp-pointed bistoury. URETHRITIS. Urethritis in the child is of very unfrequent occurrence, yet occasionally a case will be met Avith. It is pretty difficult to determine the cause of the inflammation. Sometimes it is un- doubtedly venereal, and has been contracted from the clothing of some persons about the house affected with the disease, or some- times by being nursed by such persons. The only case I ever met Avith Avas as marked a case of gonorrhoea as ever I saAv in the adult. The boy Avas about four years old, not yet in pants, and Avas nursed frequently by an uncle Avho Avas suffering from the disease. Symptoms.—The chilel will complain of pain in passing urine, and if the disease is severe, will suffer intensely from this cause. Upon examination, the prepuce will be found much SAVollen, the penis tender, and a more or less abundant discharge will pass from the urethra. 378 DISEASES OF CHILDREN. Treatment.—Of course, it is hardly pe>ssible to determine the cause of the difficulty, and Ave Avill tieat it as a simple in- flammation. The parts should be kept scrupulously clean, and if the inflammation runs high, a Avarm hip-bath may be used once or twice during the day, and some soft poultice at night. Internally I Avould prescribe, ly Tincture of Canabis Indica, Tincture Veratrum, aa. gtt. v., Avater 5iv.; a teaspoonful every two hours. The bowels might be opened with a saline cathartic every three or four days, but active catharsis is to be avoided. HYDROCELE. Hydrocele is occasionally met Avith in young children, and gives rise to considerable alarm upon the part of the parents. In some cases it is congenital, the inguinal canal not having been closed after the descent of the testes. In these it may sometimes be associateel Avith congenital hernia. Our attention having been called to the enlarged scrotum, Ave will endeavor to determine its cause by an examination. If the enlargement is caused by the distension of the tunica vaginalis with Avater, palpation Avill detect the movement of the fluid, and when the chilel cries we Avill find no movement communicated to the swollen scrotum. On the contrary, if a scrotal hernia exist, the movements of the diaphragm in the act of crying, will be communicated to the hand supporting the scrotum. In this case also, there will be no movement from side to side, as when dis- tended Avith fluid. The diagnosis betAveen hydrocele anel hema- tocele is readily effected in the child by the marked change of color in the last. Treatment.—In some cases Ave will be successful in removing the fluid and curing the disease by a stimulating application and compression. The use of a strong infusion of Hamamelis, with a Avell adjusted bandage, in.the usual form of a suspensory band- age, Avas attended with success in one case that came under mv notice. Mayer's ointment would prove a good application, as would also a soft piece of leather, cut to fit the part and spread with our ordinary strengthening plaster. Tincture of iodine has been recommended as an application to the part, to stimulate ab- sorption, but I think it would be too irritating. If these means should not succeed, the scrotum may be punc- INFANTILE LEUCORRHCEA. 379 tured with an exploring needle or small trocar, and the fluid draAvn off. If uoav the part is supported by a Avell adjusted bandage, avc may expect a radical cure. IN F A N TIL E L E U COR R H (E A. A slight discharge from the vulva is not of unfrequent occur- rence in children from one to twelve years of age, but it is only in exceptional cases that it is severe, anel produced by an active inflammation at first, but Avhich, as it declines, becomes chronic anel very stubborn. These last are very troublesome eases, and are a source of great annoyance both to the physician anel the family. Causes.—The slight discharge is the effect of cold, after over- exertion in the use of the Ioavci* limbs, or occasionally from sit- ting on the damp ground, or a stone This may also be a cause of the active inflammation, or it may be produced by acridity of the urine, irritating and excoriating the vulva, the inflammation arising in and extending from this part. In some cases it may arise from Avant of cleanliness, especially in those avIio are badly nourished. Then Ave have exceptional cases, in Avhich the inflammation is specific in its character, and is produced by contact Avith gonor- rhoea! virus. This may occur in a house where some person has gonorrhoea, from sitting on the privy seat, or by the use of cloths impregnated with the virus. Pathology.—In the slight cases there is simply an increaseel circulation in the. parts, and activity of the mucous follicles. Usually this is confined to the glands about the vulva, anel the vulvo-vaginal glands. In the severer form, there is a avcII marked inflammation, in- volving the parts about the commencement of the vagina, the vulva, and sometimes extending up the entire length of the vaginal canal. The inflammation h)ses its active character after the first ten days, and the parts present a swollen, deep-red ap- pearanee, 'bathed with muco-pus. There is no means of deter- mining from the appearance of the parts, Avhether it has arisen from gonorrhoeal virus, or not. Treatment.—The treatment is unsatisfactory in many cases, from the difficulty Ave experience in getting a proper application 380 DISEASES OF CHILDREN. of local remedies. Indeed, with the best assistance the mother can give, we make but sIoav progress. I put the child upon the use of Aconite with Cannabis Indica in the usual doses; or in place of the last Ave might give the Gel- seminum. The bowels are gently opened by citrate of magnesia or phosphate of soda every two or three days. If the child is old enough to take it, she may use an infusion of equal parts of Althaea and Uva Ursi as a drink. I now use salicylic acid and borax or chlorate of potash as the local application, as—R> Salicylic Acid, Borax (or Chlorate of Potash), aa. gr. xx., Avater Oj. This maybe applied to the vulva only, or if the discharge is vaginal it may sometimes be used with a syringe. Bathing the parts with hot water alone (as hot as can be borne comfortably) will sometimes effect a cure. The hot bath may extend to tho abdomen and spine. Perseverance in these means will relieve the acute inflamma- tion, and many times will effect a radical cure. But if a chronic discharge continues, Ave Avill obtain the best results from the local use of a solution of Sulphate of Hyelrastia grs. iv., to Avater §iv. There are many other local remedies that have been used in this case, but they are the same as recommended for the adult, and for these the reader is referred to treatises on disease of women. The general treatment in the chronic form of the disease, Avill be of a tonic and restorative character. Further than this, it is doubtful if any internal remedies can be used with benefit to the local disease. ? ONANISM. The practice of onanism is of very common occurrence after the tAvelfth year, or about the commencement of puberty. But at an earlier age than this, Ave will find occasional instances of the vice, Avhich Avill give us much trouble. I have seen it as early as the second year, anel in one case, the boy being in his fourth year, it had proven a cause of severe constitutional dis- turbance It is difficult to determine the cause of the habit in children of this age, as the organs are yet undeveloped, and Ave are taught to believe that the venereal appetite is not present until the age of puberty. It is my impression that the habit of handling the parts, is sometimes attained at a very early age, and attended ONANISM. ■SI with erections, is found pleasurable, and is repeated for this reason. I have noticed this occasionally, anel even in this slight degree, if continued but for two or three months, it will give rise to marked irritability of the nervous system and impaired health. In the severe cases Ave find the child has lost flesh and is much debilitated. There is marked depression of the nervous system, and the child has a furtive anel uneasy look. It is easy to see that the mind is affected, that the child does not receive natural impressions, and that its reasoning poAver is impaired. Some- times it seems to suffer from spinal disease, at others from disease of the loAver extremities, and again from disease of the brain. Some cases seem to be dependent upon inactivity of the stomach and be>wels—dyspepsia—anel treatment is direct- ed to this Avith the expectation of restoring the health and strength, by the use of bitter tonics anel restoratives. I recognize the difficulty by the furtive uneasy look of the patient, and by the disposition to rub the thighs together, and move the loAver part of the body. In the milder cases, the chilel does not seem to appreciate but Avhat it is all right, and Avill carry the hand to the penis while you are conversing Avith him. In the protracted cases, the child seems as much impressed with the offense as the adult, especially if he has been reproved for it; and practises it secretly Avhenever he has an opportunity. If the penis is examined in these cases, the prepuce will be found reel anel irritated, ami occasionally the organ Avill be more developed than is usual at the age. If continued, the practice Avill lead to epilepsy, idiocy, or to such impairment of the general health that the chilel Avill die early of some cachectic disease. Treatment.—In the milder cases, those Avhich have continued but a month or two, Ave may break up the habit by close atten- tion and mild reproof. Gentle means are much better than harsh, persuasion than force, anel if the matter is properly pre- sented to the parents, and they will take advice, we will get along with the patient Avell. AVhen the habit is well-established, I put it beyond the child's power to continue it, by vesicating the surface se) that handling Avill be painful, anel an erection impossible Tincture of Canthar- ides, or Cantharidal Collodion Avill answer this purpose well. It 382 DISEASES OF CHILDREN. should always be applied without the patient's knoAving of the purpose for which it is used, Avhich can very readily be done, and it shoulel be so repeated that for one or two months the organ must remain at rest. In the meaiiAvhile, by the use of tonics and restoratives, nutri- tious diet, baths, and exercise in the open air, we restore the general health, and at the end of a couple of months Ave find the habit broken and the health restored. If the difficulty should still continue circumcision is a most effectual remedy. If parents will not consent to the complete removal of the prepuce, it may be slit up on a grooved director, and the glans exposed. CHAPTER IX. DISEASES OF THE NERVOUS SYSTEM. Lesions of the nervous system exert a very important influence in disease, and Ave rarely finel a case in Avhich they do not form a part, and must be estimated in the diagnosis. They also exert a more or less marked influence on all pathological changes, and it is through the nervous system, to a considerable extent, that Ave are enabled to modify and change the various processes of life. The nervous system of the child is peculiarly susceptible to the causes of disease, and as susceptible to the influence of reme- dies. Hence, minute doses of direct medicines are found prefera- ble to large doses of such as act in an indirect manner. It Avill be recollected that the nervous system is divisible into three parts—the brain, the spinal cord, and the sympathetic nervous system. The brain is the organ of the mind, and gives us conscious ex- istence, and from it the Avill calls into action the voluntary mus- cles to serve its purposes. As a Avhole it is an element of weak- ness, and draws upon the vegetative functions for its life, rather than giving strength or aid to them. The popular opinion "that DISEASES OF THE NERVOUS SYSTEM. 383 a child may have too much brain/' like many such, is founded in fact. The large orain, as compared with the body, appropri- ates an excess of blood, nutritive material, and vital or fe>rmative power, and the remainder of the body suffers in consequence. It is essential to success, in some cases, to see that this morbid groAvth of the brain be arrested. This is accomplished by adopt- ing such a course of training as Avill develop the body and keep the mind at rest. The basilar portion of the brain is an expansion of the spinal cord, anel influences vital processes. The tenacity of life and power of living depend, to a very considerable extent, upon its development and perfect condition. AVe have already seen that this power may be very closely estimated by a measurement de- termining the depth of the basilar portion of the brain. The spinal cord is the center of reflex action, or automatic movements. It carries on certain functions when the Avill is in abeyance, and others that are but partially under the influence of the Avill. The functions of respiration, deglutition, defeca- tion, etc., and all the involuntary movements, are carried on un- der its control. Nerves from this source pass to all parts of the body, and Ave knoAV that they may take complete control of all the voluntary functions, usurping the place of the brain. The sympathetic nervous system presides over the functions of A-egetative life, controlling digestion, assimilation, blood-mak- ing, the circulation of the blood, nutrition, waste of tissue, "secre- tion and excretion. Though the entire amount of gray nerve substance in the sympathetic ganglia of the body Avould not be the size of a pigeon's egg, it is probable there is no structure in the body, hoAvever minute, but Avhat receives nervous supply from this source. DETERAIINATION OF BLOOD TO THE BRAIN. Determination of blood to the brain is of frequent occurrence in acute disease. AVe understand that determination is the result e>f irritation, but Ave can only account for this by the supposition that it follows from the accelerated circulation and increase of temperature. The immature brain is very susceptible to irrita- tion, and but slight change in its vital condition is required to induce it. 384 DISEASES OF CHILDREN. Symptoms.—Determination to the brain is announced by the increased restlessness and irritability of the patient. The face is flushed, the eyes bright, the pupils contracted, and the head hot- ter than usual. These symptoms gradually increase until they become very marked, the child suffering severely from it, and occasionally having convulsions. AAith determination to the brain all the other symptoms are increased The pulse is more frequent, the temperature higher, greater arrest of the secretions, less disposition to sleep, and fur- ther impairment of the digestive organs. It may continue to increase until an inflammation is estab- lished, or after some days terminate in the opposite condition of congestion, from exhaustion of the irritability of the brain. Treatment.—The treatment of determination of blood to the brain in childhood is direct and certain. The use of Gelseminum, associated with the special sedatives, Avill meet the indications in almost every case. But the specific action of tlie remedy is only obtained from the one preparation-—a tincture made from the green root; the most that is sold is Avholly worthless for any pur- pose in medicine. In this form I prescribe it in the folloAving proportions: ly Tincture Gelseminum gtt. v. to gtt. x., Tinct. Aconite gtt. a\, water 5iv.; a teaspoonful everyone ortAvo hours. If the features are contracted, expressive of pain, and the child starts in its sleep, and cries out shrilly, Rhus will take the place of Gelseminum, in the proportion of gtt. v. to Avater .^iv. With this treatment we employ the general bath and the hot foot-bath ; the last frequently repeated, and if the head is hot, it is sponged with warm Avater, and evaporation is promoted by fanning. Catharsis, counter-irritation, and ice to the scalp, should be avoided. CONGESTION OF THE BRAIN. Congestion is that conelition in which there is excess of blood in a part, with its movement impaired. It may arise from irri- tation of the brain at first, but usually depends upon some cause which depresses the vitality of the organ. The circulation is feeble and sluggish, while the vessels are unduly distended, and necessarily the function of the organ is impaired. PIIRENITIS. 385 Symptoms.—The child is dull and inactive, wants to sleep much, anel usually sleeps with its eyes partially open. The dull- ness and hebetude are so marked that they cannot escape notice. As the disease progresses Ave find this condition increased; the child sleeps a considerable part of the time, but it is ne)t so much s>!eep as stupor, and gradually this passes into coma, which at last becomes so profound that the child can not be arouseel from it. With this condition of the brain the Avliole system sympathizes, anel there is atonv Avith tenelencv to sluggish circulation, and consequent arrest of function in every part. Treatment.—This conelition of the child, like the preceding, I prefer to treat with a specific, rather than te> depend upon the old means—counter-irritation and catharsis. Belladonna is the remedy, anel I would prescribe it in the following form: ly Tincture of Bellaehmna gtt. A'., Tincture Aconite gtt. ij. to gtt. v., Avater oiv., a teaspoonful every hour. I think the remedy Avill veu-y rarely disappoint expectation, as I have successfully em- ployee! it for this purpose for many years, anel it has been used very extensively by others Avith like results. It may be aieleel by the use of the hot mustard foot-bath, con- tinued for thirty minutes at a time, and repeated two or three times a day, and in very severe cases by dry cups to the neck. AVhen the conelition is so marked, that it will evidently prove fatal if not speedily removed, I have been accustomed to employ a prompt and thorough emetic, anel follow with the Belladonna. This treatment may be recommended in those very severe cases sometimes met with in the eruptive fevers, in Avhich the emetic will throw off the profound coma, and give freedom to the circu- lation and the respiration. I trust to the Belladonna to accom- plish this result in children under one year, and it has so far proved satisfactory. Still there are very many who will -not have faith in such small doses of a single remedy, for the relief of so grave a condition. P II R E N I T I S. Inflammation of the brain is of more frequent occurrence in childhood than in the adult. It is rarely an idiopathic disease, but when seen it is a complication of some other affection, usu- 386 DISEASES OF CHILDREN. ally a fever or inflammation. As it is preceded by determina- tion of blood, the symptoms of Avhich are Avell marked, and the remedies employed almost specific, an imflammation of the brain should be of \rcry rare occurrence. Causes.—An inflammation of the brain may arise from a*ny of the causes that Avould produce inflammation of any other organ or part; but, as Ave have seen above, such origin is very rare. Occurring, in a majority of cases, during the progress of an acute fever or inflammation, it is dependent upon an irrita- tion produced by the accelerated circulation and increase of heat. It occurs in such persons as have a natural irritability of the brain and nervous system. These changes prove sufficient to establish an irritation, Avhich is followed by determination and inflammation. Pathology.—The inflammation may be confined to the dura mater and arachnoid—cerebral meningitis; or it may affect the substance of the brain itself—cerebritis. But it is impossible, by the symptoms presented, to determine the difference betAveen the tAvo during life. The inflammation presents its usual features; a first stage, in Avhich there is an active circulation, the structures being filled with blood, and presenting similar appearances to those seen in superficial imflammation; and a second stage, in Avhich there is stasis of blood and exudation into the connective tissue. Post-mortem examination sIioavs the seat of the lesion. If of the membranes, the dura mater and the arachnoid will be found injected in patches of greater or less extent. There is also an increased quantity of fluid, sometimes but little changed, at others moreorlessviscid,orcontaining flocculi of coagulable lymph. AVhen the acute stage has continued for three or four days, Ave sometimes find adhesions between the free surfaces. AVhen the substance of the brain has been involved, the vesicles of the pia mater are distended, and on making an incision into the convo- lutions, the cut surface will present a more uniform red color than natural, and the puncta vasculosa are more numerous anel larger. Symptoms.—The invasion of the disease is indicated by a sense of fullness and pain in the head, the integuments beino- suffused, and sometimes a marked sense of heat. Frequently phrenitis. 387 the patient complains of dullness, Avith confusion of ideas and forgetfulness, and unquiet sleep. Extreme irritability anel fret- fulness, with indisposition to sleep, and frequent startings dur- ing rest, the cry being sharp and quick, as if terrified, are the precursory symptoms in children. The disease is usually ush- ered in with a marked rigor or chill, continuing for an hour or two, or sometimes for nearly a whole day. Following this, there is in most cases high febrile reaction, the skin is hot and flushed, the pulse frequent and hard, tongue coated white, bow- els constipated, and urine scanty and high-colored. The head is turgid and hot, the eyes more prominent and suffused, the pupils contracted and fixed, and a deep-seated, heavy pulsating and tensive pain in the head. As the disease progresses, the patient becomes more irritable anel restless, the pain in the head increases, there is intolerance of light, ringing in the ears, anel intolerance of sound, sleepless- ness anel delirium. Up to the third or fourth day the fever is usu- ally continuous, though sometimes there is a slight remission in the forenoon, and the head symptoms increase or continue Avith- out abatement. A marked change is now observed, the acute sensibility gives Avay to torpor, and the delirium becomes Ioav and muttering, or is replaced by coma. The pulse becomes fuller, softer, or slow, or in some cases very hard and frequent. The head and trunk are still hot, the face turgid and of a deeper color, or in some cases blanched and contracted, the pupils dila- ted, the extremities cool, respiration difficult and sometimes stertorous, and more or less involuntary movement and starting of the tendons. The coma gradually becomes deeper, and the in- sensibility more marked; all the functions are feebly perfe>rmed, the patient lies on his back, slips down to the foot of the bed, grasps at imaginary objects, and thus slowly sinks. According to Copland: "In some cases, particularly those in Avhich the cer- ebral substance is early and generally inflamed and turgid, in- stead of phreuitic delirium, an apoplectic sopor, often preceded by convulsions, quickly supervenes; with a sIoav pulse, stertor- ous, sIoav, or labored breathing, turgid or bloated countenance, startings of the tendons, involuntary evacuations, torpor of the senses, and flae.-cidity of the limbs." Here the first stage is very short, or not noticed, and the disease passes rapidly to a fatal termination. In children Ave frequently find inflammation of the brain 388 DISEASES OF CHILDREN. making its appearance during the progress of other diseases. The head becomes hot, the face turgiel, the pupils contracted, Avith great restlessness and cemstant movement e»f the head. Though imt very marked on account of age, the chilel is. evident- ly delirious, and the frequent movement of the head, anel putting the hanels up to it, shows that it suffers pain. In other cases the acute stage has passeel Avithout notice, the face is blancheel anel contracted or Avhite anel puffy, the pulse is small and very fre- quent, the extremities cool, boAvels loose, the operations being unnatural and offensive, there is continued movement of the head and restlessness, e>r a eleep stupor or coma. Sometimes the symptoms will continue for three or four days, but at other times the disease will terminate fatally Avithin forty-eight hours. Diagnosis.—It is not eliffie-ult in the most of cases to de- termine the presence of phrenitis. The heat and turgidity of the face anel scalp, the deep-seated and tensive pain, contracted pu- pils, and the great irritability and restlessness, Avith the high grade of fever, are sufficient for the diagnosis. In those other cases in which coma, difficult respiration, full but oppressed pulse, coldness of the extremities, dilated pupils, etc., are the at- tendant symptoms, the diagnosis Avill be very difficult, and if Ave can not have the previous history of the case, almost im- possible. Prognosis.—In the first stage of the disease, the prognosis is usually favorable, if prompt measures are adopted for the arrest of the inflammation. In the second stage the lesions are so great that Ave Avill have to be guarded in our prognosis, though a con- siderable number Avill recover. Treatment.—If called to a case in the first stage of the disease, we have the patient thoroughly bathed with the alkaline wash, drying with brisk friction ; this is followed by a hot mustard foot-bath, continued for half an hour, and both are repeated once or twice daily. Internally, I prescribe—fy Tinct. of Aconite gtt. v., Tinct. Gelseminum gtt, x , water 5iv.; a teaspoonful every hour. If the fever runs high, I would add to this, Tinct. of Ve- ratrum gtt. x., for a feAV hours. To lessen the heat of the head, Ave direct that it be sponged with warm Avater and fanned, to produce evaporation. AVe will find quite warm water is very agreeable to the little patient, re- PHRENITIS. 389 lieving the excitation of the nervous system, and lessening the temperature AVe never apply cloths wrung out of cold Avater, as is the common practice, or blaehlers of pounded ice, as recom- mended in most Avorks. This is not nature's method for remov- ing surplus heat, as is the case Avith the plan first named. On the contrary, it is directly depressant in its first influence, and if^not persistently applied there will be a corresponding reaction; if, therefore, it is continued, the depression may cause death ; if suspeneleel, the reaction is higher than before, and the patient in greater danger. I do not approve of the use of a cathartic in all cases, for Avhile in some it will prove beneficial, in others it exerts an unfavorable influence Never give a cathartic when the tongue is contracted, reddened around its border and Avhite in the center, or Avhen it is ehmgated and pointed. In this case it is quite certain te> irri- tate the stomach and upper intestine, increasing the febrile action anel the disease of the brain. It may, hoAvever, be used with good effect Avhen the tongue is moist, somewhat broad, and tole- rably uniformly coated with a yellowish or grayish fur. I would prefer a small portion of jalap with a saline, as—ly Jalap grs. iij. to grs. v., Bitartrate of Potash gr. v. to grs. x. If the tongue is thus coated, sulphite of soda, in doses of tAvo to five grains, may be given every two or three hours, until the tongue cleans. So soon as the influence of the special sedative is observed, Ave may prescribe a solution of acetate of potash, to be taken largely diluted with Avater. I usually give it as a drink, and as the child is thirsty it Avill be taken pretty freely. In some cases Rhus is a very important remedy, and replaces the Gelseminum. The indications are usually very clear : the pulse is sharp, the tissues about the eyes anel base of brain con- tracted, with evident frontal headache, and the tongue shows the red papillae at its tip. If the child is .wildly delirious, anel clutchesiat its mouth and throat, Stramonium may be given with Veratrum, aa. gtt. v., water oiv.; a teaspoemful every hour. There is one point in the treatment that shoulel not be ne- glected— keeping the child quiet—rest to the nervous system being essential to complete recovery. I prefer that the child shall re- main in the recumbent position in its crib or bed, with the room darkened, and as little noise as is possible. 390 DISEASES OF CHILDREN. In some cases there is extreme irritation of the stomach, and it becomes important that this should be relieved. The Aconite and Gelseminum will have to be in very small dose, and Ave may need to add portions of Aconite anel Gelseminum to the water that Ave sponge the child's head Avith. If this is not sufficient to relieve the irritation, peach bark may be used, or a small portion of a Seidlitz powder may be given with the drink. If the tem- perature is high, cold packs may be used over the stomach and boAvels; if the child is feeble, hot packs or sponging will be bet- ter. With a temperature of 105° I shoulel think of an enema of of four to eight ounces of cold salt Avater; with cool extremities, the \A*ater should be as hot as the patient can bear it. In the second stage, the condition is wholly changed. Instead of the active circulation and excitement of the brain, Ave have a stasis of blood and coma. Locally, I order dry cups to the neck, and sometimes to the spine, with the hot mustard foot-bath; the first being repeated if the case is severe, and the second used tAvo or three times a day. Evaporating lotions are applied to the scalp, as sulphuric ether, alcohol, or cologne; sometimes a camphor or arnica lotion will ansAver the purpose well. Internally, I prescribe—Py Tinct. Aconite gtt. v., Tinct Bel- ladonna gtt, x., Avater 5'iv.; a teaspoonful every hour. Or if there is fullness of the fontanelles or swollen eyelids, Ave might add Tinct. Apocynum gtt. x. to water 5'iv., and give in teaspoon- ful doses alternately with the Belladonna. If there is retention of urine, e)r sluggish passage, Santonine may be given in doses of one-fourth to one grain, as heretofore named. If there is the conelition of the tongue named above as per- mitting the use of a cathartic, I should give—Py Jalap grs. iij., Capsicum gr. £, Bitartrate of Potash, gr. x., and repeat it every four hours until it acted freely. To act upon the kidneys, I would prefer SAveet spirits of nitre in doses often or fifteen drops, every two hours, as it is also an excellent stimulant. In some cases AA'e will find quinine inunction to answer a verv good purpose. If there is much prostration and feeble circula- tion in the skin, some rubefacient may be added to it, as one of the essential oils, or the oil of mustard in very small quantity. If the quinine is not used in this way, it may be given internally to the extent of two grains a day, during convalescence. ACUTE HYDROCEPHALUS. 391 ACUTE II Y D R 0 C E PII A L U S. AVe use this term, for the want of a better one, to distinguish a certain class of cases in Avhich the disease of the brain is a principal lesion, though the symptoms Avould indicate something else. The disease is confined almost entirely to children, occur- ing most frequently from the ages of one to three years, and being rare after tAvelve. It is very difficult to determine the cause, though we are of the opinion that it is frequently dependent upon irritation of the digestive apparatus, or upon any cause that Avill enfeeble the system. At the age of ten or tAvelve it is usually brought on by over mental exertion. Pathology.—The lesions observed in this elisease are by no means constant. In some'cases there is considerable effusion into the ventricles and the cavity of the arachnoid, but in others there is very little or neme. Sometimes there is evidence of determina- tion of bh)oel, anel occasionally small patches of lvmph or flocculi in the effused fiuiel; rarely the brain exhibits evidence of sIoav inflammation. "The nature of acute hydrocephalus," says Dr. Bennet, "has been keenly disputed, anel whether it be inflammatory or non- inflammatory, and shoulel be treated Avith antiphlogistics or nu- trients, will be founel to be discusseel at great length in systematic works and numerous monographs. The fact is, that the group of symptoms indicating the occurrence of Avater on the brain is altogether insufficient to prove the existence of this morbid pro- duct in acute cases. AA nat Ave observe are symptoms of excite- ment, gradually passing into those of depression, occasionally passing into paroxysms of pain, restlessness or screaming, alter- nately with droAvsiness anel coma. These symptoms are com- mon to various lesions of the brain, and may be the result of congestion, or of this state terminating in effusion and frequently in exudation. Hence, Avhy sometimes after death Ave find no lesion Avhatever, at others more or less distension of the ven- tricles with serum, and very commonly, in addition, exudation at the base of the cranium. In every case, the symptoms are referable not so much to one or the other of these lesions as te) something Avhich they all have in common, and this undoubtedly is more or less pressure on various portions of the brain, causing, 10 392 DISEASES OF CHILDREN'. first, irritation and then perversion of function, or so operating as to excite some parts and to depress others. In the great ma- jority of cases, the fluid distending the ventricles is more allied to the dropsies than exudations. Nay, even Avhen lymph is throAvn out at the base of thevbrain, the amount of serum in the ventricles is altogether disproportioncd to the quantity of coagu- lated fibrin deposited. Hence, I am elisposed to think that even when evielence of so-called inflammation exists, still the fluid that distends the ventricles is owing to a mechanical obstruction of the vessels, causing dropsical effusion." Symptoms.—At an early age, Ave find the elisease commencing as an obscure remittent fever, the languor, or more properly stupor, being the most prominent symptom. The fever usually has an exacerbation in the afternoon, the child being restless and fretful at this time Nausea and vomiting are very frequently present, especially if there is irritation of the boAvels, forming one variety of cholera infantum. In a longer or shorter time, usually not more than from tAvo to ten days, the patient becomes almost entirely unconscious, though from the occasional glance of intelligence it is not believed by the parents. Still it is rest- less anel uneasy, turning its head from side to side, putting its hanels to its head, and uttering those sharp, piercing cries indic- ative of pain ; if the tongue can be seen, it Avill be found dry, its tip and edges red, and center covered with a white coat. The countenance is iioav pallid anel pinched ; the eyes Avant expression, and are sunk in the head, the pupils generally dilated; the head is not above normal temperature, frequently dry, although the forehead is covered Avith a clammy perspiration. If there ■.'as not diarrhoea at the commencement, there is iioav, the stools being of a dirty-yelloAvish or greenish color, mixed with slimy matter and having an offensive odor. A very common grouping of symptoms is thus reported in a clinical case by Dr. Bennet: "Unconsciousness e>f surroundim* objects, not recognizing even her mother ; pupils not contractile to light; slight strabismus of right eye; frequently puts her hanels to the head, which is rolled about uneasily; continual grinding of the teeth, low moaning, anel occasional muttering. Tip of tongue, which is all that can be seen, very dry and e>f a scarlet color; loss of appetite ; constant thirst ; vomiting ; invol- untary discharge of feces and urine; on pressing the abdomen acute hydrocephalus. 393 uneasiness evidently experienced, and moaning increased; skin hot anel dry ; no eruption ; a small abscess at the back of the neck, Avith a sanious discharge; action of the heart feeble and fluttering; pulse one hundred and forty, small, anel occasionally intermittent. Breathing short and hurried ; no rales." These symptoms Ave re eleveloped in a child aged six, commencing four- teen days previously with diarrhoea. In older children the first symptoms will be a more or less severe headache, with intellectual stupor, the child being restless and uneasy, and passing bad nights ; an obscure fever may be recognized in the after part of the day, the skin being dry and husky, anel the pulse frequent and hard. For days, and even for two or three Aveeks, the symptoms continue in this Avay, the chilel being occasionally better fe>r a few hours or sometimes for a day or tAvo. Suddenly the pain in the head becomes intense; the face is pinched and expressive of great suffering ; the tongue is red at its tip anel edges, dry, and its center covered with a white coat; the bowels constipated, or there is diarrhoea ; urine scanty; the pupils dilated, and immobile on exposure to light. The child does not like to be disturbed, is constantly dozing, though its nights are restless. The-pulse maybe either frequent anel sharp, or in some cases slenv anel feeble. Very frequently there is nausea anel vomiting, sometimes very persistent and intractable These symptoms becoming very severe, deep coma results, from Avhich the child never recovers, but two or three days elapsing from its accession until the fatal termination. Diagnosis.—I diagnose this disease by the pinched expression of the countenance, every part seeming to be contracted, the dilatation of the pupil, the stupor and at the same time restless- ness of the patient. These symptoms may be confounded with the second stage of inflammation of the brain, but the prior symptoms are usually sufficient for the diagnosis. Prognosis.—It is very difficult to so describe this disease, that the reader may determine which cases will recover, anel which will unavoidably prove fatal. Usually, if the child is still conscious, and there is not such marked contraction of the countenance, as te) render it hippocratic, Ave may hope for a favorable result ; if the contrary is the case, it will in all proba- bility prove fatal. 394 DISEASES OF CHILDREN. Treatment.—The treatment Avill have to be much modified to suit each individual case; yet in every one it must be decidedly stimulant and sustaining. If there is continuous nausea, with evidence of morbid accumulations, the stomach should be re- lieved by the administration of a prompt emetic, very marked benefit following its action. In other cases the nausea may be arrested by a sinapism over the epigastrium, and the administra- tion of an infusion of peach-tree bark, or compound penvder of rhubarb and potassa. Injections of salt and Avater, an even tea- spe)onful to four ounces of water, will sometimes prove very efficient in irritation of the stomach ; chloroform and glycerine may be used for the same purpose, and may aftenvards be con- tinued in doses of five drops every hour or tAvo, for its stimulant and at the same time soothing influence. If there is diarrhoea, it is the generally received opinion that it should be checked by the use of astringents ; but this is bad practice as almost invari- ably on the arrest of the discharges, the coma becomes complete, and the child dies. Remedies shoulel be very carefully selected in these cases. Aconite anel Ipecac, in small doses, will sometimes quiet irrita- tion of the stomach and relieve this irritation. Gelseminum may be indicated as in inflammation of the brain. Belladonna is called for Avhen dullness anel stupor become marked symptoms. Rhus Avill sometimes prove a most valuable remedy, there being a sharp frequent pulse, contraction about the eyes and base of the brain, sudden startings in sleep with shrill cry. A\Tith the relief of irritatiem of the stomach, and to a certain extent of the brain, Apocynum becomes a prominent remedy, though it must be used in small doses. R> Tinct. Aconite gtt. iij., Tinct, Apocynum gtt. v., Avater Siv.; a teaspoonful every erne or tAvo hours. If indicated, Rhus or Belladonna should be substi- tuted for the Aconite. If the tongue is pallid and dirty, sulphate of soda should be given in doses of two to five grains every three hours. If red and dirty, sulphurous acid will be the remedy. If drvand harsh, the child's drink may be acidulated Avith muriatic acid, or it can have small portions of good sharp cider, or in some cases, of whey. The hot mustard foot-bath will be sufficient in some cases, if thoroughly used, but if the case is severe, I prefer a tub of Avater as hot as the child can bear it, and rendered stimu- lant by the addition of mustard or capsicum, into which I put the CHRONIC HYDROCEPHALUS. 395 child, letting it remain for half an hour, being Avell covered with a blanket, In place of this, sponging the surface with hot Avater, Avill answer a good purpose. Dry cupping to the neck, and even sometimes to the entire spine, is among our most important measures; sometimes the cups to the neck maybe scarified, espe- cially if there is much heat of the head. A sinapism to the neck and spine will sometimes answer the purpose, but is not as good as the cups, anel I think not as useful as friction Avith strong salt and Avater hot. If the kidneys fail to act freely, I Avould admin- ister an infusion of hair-cap moss or of marsh-mallows, Avith a suitable portion of acetate of potash or SAveet spirits of nitre. CHRONIC HYDROCEPHALUS. Dropsy of the brain is almost exclusively a disease of child- hood, and occurs most frequently before the third year. It is difficult to determine the causes that give rise to the effusion of water from the arachnoid, but as it occurs almost invariably in children of feeble vitality, and in families whose children die during infancy of acute hydrocephalus, cholera infantum, or this, Ave are led to believe that it depends upon hereditary debility. The exciting cause may be the exanthemata, Avhooping cough, disease of the boAvels, or inflammatory disease, or it may arise from depression, produced by cold anel other causes. Symptoms.—The symptoms vary very greatly, the elisease running a tolerably rapid course in some cases, and a very slow one in others. The e:hilel usually complains of its head, if it can talk, or moves it from side to side, putting its hanels to it fre- quently. The face is pallid and contracted, or in some cases puffy and Avithout expression ; the circulation is feeble, the extremities being cold, and the surface easily chilled; the appetite is irregu- lar, sometime's good, at others very poor, and digestion seems to be feeble; the bowels are torpid and constipated, though some- times irregular. As the disease progresses, we notice that the chilel is very stupid, anel that at times it has difficulty in con- trolling the voluntary musedes ; there may be temporary pr per- manent strabismus, and an iiwoluntary rolling about of the eyes, with a dilated and fixed pupil. Occasionally Ave observe a marked irritability of the stomach, that is with difficulty controlled, and in some cases an extreme 396 DISEASES OF CHILDREN. irritability anel restlessness, though the intellectual functions are greatly impaired. As the disease progresses the torpor becomes deeper, and the child does not exhibit the symptoms of pain above named. The pulse is now seen to be getting perceptibly weaker, and occasionally irregular ; the hands are tremulous and unsteady, and frequently raised to the back of the head. AVhen the child sleeps, its eves are half open, anel the eyeballs are con- stantly moving and usually draAvn upward. AVhen the torpor is not so great, the child is in some cases constantly picking its nose or lips," and is extremely irritable, having paroxysms of rage from the slightest supposed offense. The disease may con- tinue this Avay for months, or in semie rare cases for years, finally terminating fatally by the development e)f some ataxic disease, or of acute hydrocephalus, or with a gradually developed maras- mus. Diagnosis.—In very young children, and sometimes up to the age of three years, there will be found a perceptible enlarge- ment and distension of the fontanelles, and separation of the sutures, and the child's head is appreciably larger. After this, Ave are guided entirely by the general symptoms above named. Prognosis.—The prognosis is usually unfavorable, though some cases may be cured, and in others life may be prolonged for a considerable period. Cases are recorded in Avhich the persons lived to adult age, and in four cases to tAventy-seven, thirty-two, forty-five and fifty-four years. Post-Mortem-Examination.—If the disease has been of long duration, the bones of the cranium will be found thin and transparent, and occasionally separated from each other by very considerable intervals. The effused fluid is found in the sac of the arachnoid, anel in the ventricles; if in the ventricles to a great extent, the convolutions are unfolded, and the medullary and cineritious substances can with difficulty be distinguished. The brain is often denser than usual, and is not diminished in weight. Treatment.—I am satisfied that the greatest success in the treatment of dropsy will follow the use of specific remedies, and especially in the case under consideration. The remedy I prefer in this case is the Apocynum cannibinum—its substitute, Aralia hispida. I prescribe the first in the folloAving form : R. Tinct. spinal meningitis. 397 Apocynum gtt. x., Avater 5iv ; give a teaspoonful every two or three henirs. The Aralia I have used in infusion, associated Avith the tonics named below. A number of cases of hydrocephalus cured by Apocynum are on record, and I ha\Te had three cases in my practice Avhich have recovered under its use. After the use of these means for some days, their influence in removing the accumulation being observed, Ave put the patient upon the use of tonie-s, alternating them. As a tonic, some of the preparations of hydrastia answer the best purpose, and when there is constipation of the bowels, may be given Avith podophyllin in small doses ; the combination of these remedies heretofi)re given may be employed. The Collin- sonia canadensis is a favorite remedy in my "practice, especially in cases Avhere there is irritation of the nervous system, and avc may associate with it the Ptelea, Cornus, Euonymus, or other remedies of this class. Rye Avhiskey anel cod-liver oil are excellent when the stomach bears them kindly, and should it reject the oil, its place may be supplied by SAveet cream or beef-suet. The child should have a daily salt-Avater bath ; sometimes the entire bath Avill be best, and may be used either Avarm or cold, th:> first being generally preferable, or the sponge-bath may be med ; in either case it should be followed with brisk friction. The child should be taken out. in the open air every day, being warmly clad in flannel. If possible it should be removed to a high locality in the country, where it can have pure air and sun- shine, exercise and pure milk. SPINAL MENINGITIS. Inflammation of the meninges of the spinal column is not an uncommon disease, though sometimes, from the obscurity of its symptoms, it may be mistaken fe>r other affections. It occurs in two forms, as a distinct sporadic inflammation, and as an epi- demic or enelemic fever, which involves the spinal cord. It is in the last named cases that mistakes in diagnosis are most usu- ally made. The causes of this affection are those which give rise to other inflammations, as colel, sudden changes of tempera- ture, injuries, and especially a sudden chilling of the surfae-e after active exertion. It occurs most frequently in the young and vigorous, and is very rare after middle life. 398 DISEASES OF CHILDREN. Symptoms.—Spinal meningitis usually commences Avith a Avell-marked chill, lasting for several hours, though sometimes with a severe rigor of considerable duration. I have seen cases in which the chill Avas of twenty-four hour's duration, the later part of it being alternated Avith flushes of heat. FolloAving this there is marked febrile reaction, Avith hot, dry skin, hard and frequent pulse, tongue coated Avhite, the edges anel tip being red, constipation of the bowels, and scanty and high-colored urine The patient complains greatly of pain in the back, which is so increased on movement, that he dislikes to change his posi- tion fe>r any purpose; though in some cases, when not so se\Tere, they are constantly shifting their position to give them ease. By the second or third day the fever usually becomes high, the pulse running some thirty or forty beats higher than in health, the skin being very dry and constricted, and the irrita- bility and restlessness marked. These symptoms may be so pro- minent as to completely overshadow the symptoms of spinal in- flammation, the patient not even complaining of pain, unless his attention is directly called to it. It Avill be noticed, hoAvever, that the slightest movement or changing the position of the body gives rise to pain, and when the attention is thus drawn to it the soreness of the spine Avill be continually noticed. Deep pressure usually elicits tenderness, and sometimes the sensibility is so ex- quisite that the patient cannot bear to be touched. As the disease progresses, the fever assumes an irritative or typhoid type. The tongue soon becomes broAvn, and sordes ap- pear on the teeth. Typhomania occurs about the sixth or sev- enth day, and is frequently attended Avith looseness of the howeis. Sometimes there is marked irritation of the brain and delirium, at others a stupor which soon passes into deep coma. As the local disease progresses, it is found that the loAver extremities are subject to involuntary movement, and that the patient has but partial command over them ; and that the bladder and rectum are evacuated Avithout the knowledge of the patient, or there is retention of urine without the poAver of discharging it. At last, in severe cases, paralysis of the parts below the seat of inflamma- tion is complete. The fever is usually continued, though some- times remittent, and is invariably ataxic, presenting well marked typhoid symptoms, with the exception of diarrhoea, by the tenth to the twelfth day. It is usually protracted, lasting from tAvo to eight or ten Aveeks. SPINAL MENINGITIS. 399 Diagnosis.—AVe d'mgnose inflammation of the spinal cord by the marked tenderness of the spine and inability to move, the constant pain in the back, with the severe attendant fever. It is almost impossible to overlook these local symptoms, and vet in many cases they have been disregarded, to the great detriment of the patient. Prognosis.—The prognosis is usually favorable, if treatment is commenced in time, but is unfavorable after it has made prog- gress for several days, in many cases terminating fatally, or in paralysis. Post-Mortem Examination.—In some cases there is marked evielence of determination of blood to the membranes, and en- largement of the vessels. Sometimes the membranes are thick- ened, and fragments of organized lymph on the free surface; .there may also be flocculi in the fluid of the spinal cord, which is increased in quantity. In other cases the disease seems to be confined to the pia-mater anel the substance of the cord, the for- mer being slightly reddened, and sometimes thickened, and the latter softened, sometimes so much as to have lost all traces of organization. Treatment.—The treatment of this disease will vary accord- ing to the indications. In some cases Aconite or ATeratrum, with Gelseminum, will be the remedy, aud as the pulse and tempera- ture come doAvn, Ave find the symptoms of spinal irritation re- duced. In other cases the indications for Rhus Avill be marked, anel it Avill be associated with Aconite. Bryonia is indicated by the steady pain in the spine, with possibly a flushing of the right cheek. Macrotys will be indicated by muscular pain, as in other cases; Sticta by the pain in shoulders anel neck to the occiput; Phytolacca by soreness of the mouth and throat, and fullness of cervical glands. In some cases, the attack being sudden and se\rere, and the patient suffering from nausea or disgust for food, drink, or medi- cine, Ave find a full, dirty tongue, and conclude that the treat- ment had best be commenced Avith an emetic. The Acetous Emetic Tincture acts Avell, but in many cases we would prefer Ipecac in doses of two or three grains every fifteen minutes to free emesis. With a broad, pallid and dirty tongue, sulphite of soda Avill be indicated in the usual doses. If the tongue is red, and covered with a glutinous yellow coat (like fecal material) 400 DISEASES OF CHILDREN. sulphurous acid is the remedy. AVhen the face is full anel pur- plish, like one who has been exposed to severe cold, Baptis.a is given. AVhen the temperature is high Ave may sometimes obtain ex- cellent results from the colel Avet-sheet pack. It requires a little courage to use it, fen* both chilel and parents are afraid; still, if avc have a severe case, and the stomach is irritable, so that Ave do not sec our Avay clearly with other remedies, Ave will use it. If the case is severe, and there is marked impairment of the skin with exhaustion, I think Avell of the hot-blanket pack. In place of this, rapid sponging of the surface with hot Avater answers well, (it should be done before a fire, and the surface protectee! against chill by a blanket.) Any part that the patient complains of may be thus sponged. The local applications to the spine (if Ave use any) Avill vary Avith the case. Sometimes dry cups give relief. In other cases' hot spongings, or hot packs, hot bran, or a bag of hot salt, te) the part, is of benefit. I do not have much faith in liniments, and am inclined to believe that rest is better than the rubbings. As the inflammation passes aAvay the chilel may have some of the simpler bitters, quinine inunctions, the hypophosphites, oeul- liver oil, or some of the preparations of malt. CURVATURE OF THE SPINE. Curvature of the spine occurs most generally in the young, and is rare after the age of t\A'enty-fiA'e. In all cases it is the result of enfeebled vitality, either congenital or induced by des- titution, over mental exertion, or sexual excitement. In semie cases this manifests itself in the form of scrofula or tuberculosis, and in such case Ave may expect disease of the bones. Two va- rieties of curvature are met with, lateral anel posterior, both oc- curring most frequently in the dorsal region, though at last ahvavs compensated by curvature of the lumbar and cervical portions. Lateral curvature may be dependent upon affections of the muscles, as hypertrophy, atrophy, spasmodic contraction or inflammation; upon general debility, the bodv not beino-suffi- ciently strong to support itself in the erect position ; upon obli- quity of the pelvis, the result of injury or disease of the Ioavci- extremities; upon altered capacity of one side of the chest • 111101 rachitis or softening of the bones, or defective development of CURVATURE OF THE SPINE. 401 the vertebra. Posterior curvature is most generally dependent upon disease of the bodies of the vertebra, though in some cases it undoubtedly results from debility, and the habit of throwing the head and shoulders forward in sitting and walking; in the last case being very mild. Practically Ave have to study the case, first, with reference as to Avhether it depends upon elisease of the muscles or bones ; second, Avhether its continuance depends upon determination of blooel or upon feeble circulation; and third, as regards the general health, Avhether there is simple debility from imperfect digestion and assimilation, or a scrofulous or tubercu- lar cachexia. The success of the treatment will depend upon accurate diagnosis as regards these points, as in many respects it must differ in different cases. Symptoms.—The symptoms of curvature of the spine vary greatly in different cases, in semic being very marked, and in others obscure. Usually the child's health is noticed to be fee- ble, its appetite variable, and digestion and assimilation imper- fect. It may or may not complain of pain in the back, but it Avill be noticed that the back is weak, and that it makes unusual efforts to rest it. In lateral curvature, the elisease is most usu- ally dependent upon local debility of the erector muscles of the spine, and there is frequently no complaint, except from weak- ness e>f the back, and the symptoms of general debility above named. If partially owing to spasmodic action, pain would be a constant attendant, though usually there Avould be no tender- ness on pressure. If the result of disease of the bones, as in most cases of posterior curvature, in addition to more or less pain, there will be tenderness em deep pressure. In these cases the disease of the bone causes irritation of the spinal cord, and Ave have the symptoms heretofore named. Diagnosis.—An examination of the spine Avill determine the existence of curvature, and it is usually not difficult to de- termine Avhich is the primary anel which is the curvature of com- pensation. In almost all cases of lateral curvature Ave will finel the fault to exist principally in the muscles at first, though as the disease progresses, irritation is frequently developed, result- ing in spasmodic action, and finally in atrophy or softening of the bones; hence spinal tenderness will usually result in the lat- ter part of the disease, and not at is commencement. In poste- 402 DISEASES OF CHILDREN. rior curvature, we sometimes have the most marked evidence of scrofulous cachexia, and in most cases Ave have marked general debility. It will be recollected that the disease of the bodies of the vertebra may be a true inflammation, or result from deposit of tubercles and scrofulous material, or may be simple softening from rachitis. In the first case the pain will be marked and de- cided, in the seconel there is simple irritation and aching of the part, Avith tenderness on pressure; and in the last Ave Avill have the previous curvature and deformity of the legs and pelvis, in addition to the absence of pain and tenderness, to aid us in the diagnosis. Mr. Solly believed that softening of the bones might be entirely local, and might be dependent upon nervous exhaustion ; in such case the symptoms would be obscure. Prognosis.—In lateral curvature a favorable prognosis may be given in many cases, the deformity being nearly entirely re- moveel, or it maybe simply arrested, the body so accommodating itself to it as to give rise to but little subsequent trouble. In posterior curvature the best results usually obtainable is to stop the disease and prevent further curvature. It is true that in some cases Ave may partially correct the deformity, but in a large majority the attempt is attended with injury rather than benefit. If there has been destruction of the bodies of the vertebra the best result is anchylosis of the bones anel of course permanence of the curvature; and if this is prevented by instruments for extension, the life of the patient will almost surely be sacrificed. Treatment.—In all forms of spinal curvature attention to the general health is one of the most important points in the treatment. Those bitter tonics that improve the tone of the stomach, and give the patient a good appetite and power of di- gestion are applicable For the selection of these remedies, the reader is referred to the first part of this work, "restoratives," which will enable him to select the best remedy. If there is disease of the bones assuming the form of softening, phosphoric aciel has been recommended; and from the little experience I have had with it, I am inclined to belieA-e that it Avill generally be found advantageous; Ave Avould commence its administration in doses of two drops of the dilute acid, fe)ur or five times a dav, and increase it if deemed best. Phosphate of soda may be given with the food in such quantities as will keep the boAvels soluble. CURVATURE OF THE SPINE. 403 Simple lime Avater is sometimes useful, and children Avill improve Avhen it is added to their milk. Even common salt becomes an important remedy when children have not had it in sufficient quantity (bottle babies), and added to their milk there is a deci- ded improvement. Hypophosphite of lime, the compound syrup of the hypophosphites, anel some of the phosphates, may also be thought of. Occasionally veratrum and arsenic in small doses Avill improve the appetite, digestion and bloodmaking. AVhen the symptoms Avould lead us to belieA'e there Avas scrof- ulous disease of the bones, the vegetable alteratives may be brought into requisition. A combination of yelloAv dock and tag alder, with small portions of acetate of potash has ansAvered my purpose Avell. If there is great irritability of the nervous system I would substitute the bromide of ammonium for the prepara- tions of potassa. These remedies should not take the place of tonics and restoratives, but should be associated with them in such manner as that normal digestion and assimilation shall be the first object in view. A nutritious and easily digested diet should be prescribed, and frequently a small amount of malt liquor is advisable. The sponge bath should be used daily, sometimes of simple water, salt ami Avater, or stimulants, as cap- sicum or mustard, or the mineral acid baths, or of a decoction of the bitter tonics and astringents. If there is simple loss of muscular poAver, as in many cases of lataral curvature Ave Avould recommend open air exercise, and fric- tion of the spine Avith cold salt Avater, andsemietimes the use of elec- tricity. These are the only cases in Avhich exercise is permissible, and then it shoulel be so regulated as ne>t to prove exhaustive. Sir B. Brodie recommends that the muscles e>f the back be strength- ened by climbing and other exercises, for which, in delicate girls, friction or shampooing for an hour or tAvo daily might be sub- stituted; and the patient should lie down for a part or a whole of the time she Avas not engaged in exercise Mechanical support mav be used in these cases, but it should ahvays permit free movement. If in any case there is irritation anel pain, Avith ten- derness on pressure, the child should maintain the recumbent position, and especially is this the ease in posterior curvature. Rest is all-important in these cases, until the disease is entirely arrested, and though it Avill sometimes seem as if the child could not beat* the continued confinement, Ave Avill find that it absolute- ly improves in every respect, Avhile maintaining the most perfect 404 DISEASES OF CHILDREN. quiet. Counter-irritation is of much importance in these cases, but avc must be careful ne)t to carry it so far as to unduly irritate the nervous system, or induce debility by the excessive discharge. The irritating plaster is a favorite application, and will usually be found the best of any. It may, in severe cases, be replaced by the issue, and in others by two, three or four small setons, as common surgeons' silk, passed through a fold of the skin on each side of the spine. In cases of the diseases of the bones, Dr. Pirrie remarks, "That any attempt to remove the curvature Avould be injudicious. Anchylosis is the only favorable termination to be hoped for, and therefore the object to be aimed at in treatment should be to place the patient under circumstances most likely to conduce to that result. AVith that vieAV, it is indispensable, first to keep the patient in a recumbent position, so as to remove from the diseased parts the pressure of the superimposed Aveight, anel to preserve the parts in a state of perfect quietude in that position; and secondly, to use all means, judicious and available in the cir- cumstances of the case, for maintaining the general health. One particular advantage Avhich results from preserving the parts at rest in the horizontal position, is that the remoA'al of the irrita- tion caused by the superincumbent weight from the diseaseel parts diminishes the danger of the formation of abscess, which is a most unpromising occurrence, and must induce the gloomiest apprehensions as to the ultimate result." A most excellent means of attaining perfect rest is afforded by a common camp cot, Avith the head elevated about a foot, and covereel Avith a soft hair mattress; two crutches softly padded, should pass from the foot up to the arm-pits, and an india-rubber Avebbing attached to the arms of these to support the trunk. In this apparatus there is constant gentle extension ; the body is supported by the webbing, the patient lying on the back, or face doAvnward, as seems best suited to the case. For full description the reader Avould do Avell to consult Bigg on Deformities, the second volume containing most explicit descriptions of apparatus and well-draAvn wood-cuts. EPILEPSY. 405 EPILEPSY. Epilepsy is one of the most serious of the diseases of the nerv- ous system, not because of its fatality, for it runs a very chronic course, but because there is no tendency to spontaneous arrest, anel medicine has heretofore had very little influence upon it. One of the most distressing features of the elisease 'is, that it grad- ually impairs the mind, until the person, once bright and of sound mind, becomes a driveling idiot or a raving maniac. The disease usually commences in childhood, most frequently be- tween the ages of six and twelve. The causes of epilepsy are various, and not very Avell under- stoenl. They may be divided into intrinsic and extrinsic, in the first case existing in the cerebro-spinal nervous centers, or their immediate surroundings, and in the second existing at a distance, and affecting the spinal cord through the nerves. Of the first, Ave may instance inflammation and determination of blood to the cerebro-spinal centers, disease of the meninges and of the benv- els, and injuries of the bones, giving rise to compression ; or con- tinued irritation, as by the presence of a spicula pressing the nerve-substane:e. Derangements of the blood may sometimes give rise to epilepsy, as in the retention of the soliels of the urine and other changes that Ave are not cognizant of. By an extrinsic cause, Ave understand one in Avhich the irritation being set up at a distance is propagated along the nerve trunks to the spinal cord, Avhere, setting up an irritation, it manifests itself through the excito-motory system of nerves. The most simple instance of this action is witnessed in the case of cramps of the muscles of the extremities from irritation of the intestinal canal, as in cholera morbus, and in the case of infantile convulsions from teething or from gastro-intestinal irritation. Epilepsy may in this Avay arise from irritation of the stomach from crude indiges- tible food, from Avorms, from irritation of the IioavcIs, the kid- neys, or bladder, or genital organs. The cause being sufficient to set the disease going, may disappear entirely in a few days or Aveeks, and vet the epileptic attacks continue It Avould seem (hat when this abnormal action is once set up, the tendency to its continuance is the same as in healthy functiems ; but Avhy this is Ave know not, and neither can we give any probable theory. As regards the pathology of epilepsy, Ave are much in the dark. 406 DISEASES OF CHILDREN. In some cases it Avould seem to be dependent em a too free circu- lation of blood in the nervous centers—determination of blood; in other cases upon a sluggish circulation—congestion; and in still others, upon some defect in nutrition. There are cases in Avhich it is very manifest that the condition of the blood is the exciting cause of the epileptiform seizure, though we must still imagine an unnatural irritability of the nerve centers to be so impressed. Thus, I have seen cases in Avhich every convulsion Avas preceded by deficient secretion of urine ; and so long as this secretion could be maintained in the normal condition, so long Avould'the patient be free from its seizure. Cases in which the elisease is dependent upon the amount and character of the men- strual discharge, have come under the notice of almost every O 7 * one. Experience, hoAvever, has proven to me, that epilepsy is eminently a disease of debility of the nervous system, even in cases in Avhich there seems to be the most evident symptoms of irritation and determination of blood. Dr. Raelcliffe has written a most interesting paper on the pathology of convulsions, and draAvs the following conclusions: "1st. The epileptic and epileptiform paroxysm is not unfre- quently preceded by signs of defective respiration. 2d. It is usually accompanied by a state of unmistakable suffocation. 3d. The condition of respiration during convulsion is one Avhich supports the notion that the convulsion is connected with de- pressed anel not with exalted vital action. 4th. In the chronic fe>rm of convulsive disorders, the inter paroxysmal condition is usually marked by evielent signs of feeble circulation. 5th. The epileptic anel epileptiform paroxysm is usually if not invariably preceded by signs of failure in the circulation. 6th. In the fullv eleveloped paroxysm, the pulse is sometimes aroused to a con- siderable degree of activity, not because the arteries are receiving a largely increaseel supply e>f red blood, but because thev are then laboring under a load of black blood, as they are found to labor eluring suffocation. 7th. Convulsion is never co-incident with a state of active febrile excitement of the circulation. 8th. Epileptiform convulsion is a direct consequence of sudden and copious loss of blood. 9th. The conelition of the circulation during convulsion is one which supports the notion that the convulsion is connected with depressed and not with exalted vital action." EPILEPSY. 407 It is of but little use to try to study the original cause in many cases of epilepsy, for as has been remarked, it has possibly passeal away months before our examination. There is always, however, an exciting cause, which it is necessary to determine, if possible, as upon its removal, the success of our treatment will in great measure depend. I have known it to be a failure of excretion, an imperfection in digestion, derangement of the menstrual function, excessive mental emotion, and not unfre- quently excessive sexual excitement. Symptoms.—In some cases there are brief premonitory symp- toms of the approaching seizure, and rarely, the patient has no- tice of it for hours. The sensations differ in different cases: sometimes a sense of weight and oppression in the head, with giddiness and loss of voluntary poAver ; in others, a coldness pass- ing freun the feet upwards, and terminating in the epileptic seiz- ure when it reaches the bead. In the more protracted cases, there is usually a marked dullness anel hebetude, noticed by the friends, and the patient feels a loss of consciousness that is very unpleasant, In an attack of epilepsy the patient becomes suddenly uncon- scious and falls to the floor, or Avherever he may be situated. Involuntary movement from spasmodic contraction and relaxa- tion, is characteristic of the disease, and may be very intense or mild. If severe, the limbs are throAvn in various positions, the trunk contorted, and the features remarkably changed. First one group of muscles contract and then another, so that parts arc kept in constant movement. The lower jaAV and tongue be- ing also affected, Ave find that usually the latter organ is severely bitten, if means are not taken to avoid it. The patient usually froths at the mouth ; respiration is normal in frequency, and the pulse but little changed, except that it is smaller and feebler. The countenance is not only distorted by the convulsion, but in some cases is turgid and purplish, or almost black. Frequently the urine, and sometimes the feces, are passed involuntarily dur- ing its continuance. The duration of the epileptic seizure is very variable, some- times lasting but a feAV seconds, and at others for fifteen or twenty minutes. The patient may have but one attack at a time, or thcv mav succeed one another at short intervals, until quite a lar^e number have passed. AVhen the attack ceases, the patient 408 DISEASES OF CHILDREN. becomes completely relaxed, and usually falls into a deep, coma- tose sleep, from which it is almost inqmssible to arouse him for an hour or tAvo. The frequency of their recurrence varies in different cases; in some they do not appear oftener than once a month; in others every Aveek, or almost everyday. Sometimes thev are so distinctly periodic that the return can be closely cal- culated, but at others they are very erratic in their course. In many cases there are slight seizures eluring the intervals between the principal attacks; in these the patient seems to lose conscious- ness for but a moment, anel stares vacantly at persems present; passing off, he has no recollection of it, nor of the epileptic attack. Diagnosis.—We diagnose epilepsy from apoplexy by the fact that in the first there is continual spasmodic action, Avhile in the last there is not the slightest motion ; in the one there is frothing at the mouth, in the other it occurs but rarely; in apoplexy the respiration is slow and stertorous, and the pulse full and sIoaa', while in epilepsy respiration is of usual frequency without ster- tor, and the pulse is small and frequent. A\re diagnose it from hysteria by the previous history of the case, and by the fact that Ave are able to determine that there is not complete loss of con- sciousness in the latter case. Prognosis.—So far as regards the cure of the disease, the prognosis is unfavorable, unless the means here recommended prove more serviceable than those heretofore used. But, as be- fore remarked, it runs a course of years, and the patient dies finally of some other affection in a great many cases. Post-Mortem Examination.—In a majority of cases the scalpel reveals no lesion to account for the severe disturbance of the system during life, and what lesions are found generally have no relation to the epileptic affection. In some cases the evidence of sIoav inflammatory action is found in the brain or spinal cord, or, in rare cases, a morbid growth in the nervous substance, e>r from the meninges or bones, is observed, and in others a change of structure, usually softening, has occurred. These, however, form but a small fraction of the cases. In other instances some organ, as the stomach, kidneys, uterus, etc., is found diseased, and as the epilepsy made its first appearance Avith the symptoms of these diseases, Ave have good reasons to believe that they acted as exciting causes. EPILEPSY. 409 Treatment.—The treatment in these eases is of tAvo kinds: that for the arrest of the paroxysm, and that for the radical cure ot the elisease. If called to see a persem suffering from an attack of epilepsy, Ave wouhl place the patient in such a position that he would not be likely to injure himself, anel if the convulsive action was severe, get a friend to holel a cork or piece of soft Avooel between the teeth to prevent biting the tongue Usually this is all that is necessary, except in cases where the patient has a succession of attacks. In these cases, as soon as the first par- oxysm commences passing off, we may administer the compound tincture of Lobelia and Capsicum in half-teaspoonful doses every five or ten minutes, until nausea is induced, Avhich, in a large majority e>f cases, will prevent a return of the convulsion ; or Ave may use the tincture of Gelsenrinum fi>r the same purpose, giving it in doses of from ten to tAveuty drops, or even half a drachm of the common tincture, every ten or fifteen minutes, un- til the full relaxant influence of the remedy is produced. A com- bination of sulphuric ether, liquor ammonia, and tincture of asa- foetida may be used for the same purpose, but it is not as efficient as the preceding measures. If need be, stimulant applications may be made to the Ioavci* extremities and to the spine, but usu- ally this is not necessary. As regards a radical cure, Ave may attempt it in all cases in which there is no structural lesion of the spinal cord en* brain, or their enclosures, to account for the disease If there is, the case becomes one for the surgeon rather than the physician, though operations thus far have proven very unsuccessful. If Ave can detect any lesion of function, especially if it seem to bear a rela- tion to the epileptic seizure, Ave would employ remedies fe>r its removal. Thus, in rare cases, a cure will result from the removal of worms, and relief of irritation of the intestinal canal; from the relief of menstrual irregularity; by establishing anel maintaining free secretion of the kidneys, when functional lesion of these organs has been prominent, etc. In some eases the disease ap- pears to be dependent upon spinal irritation and determination of blooel, and occasionally a cure may be effected by the use of the irritating plaster to the spine, the administration of tincture of Gelseminum and the use of those other measures recommended under the head of spinal irritation. Belladonna, ergot, and nux vomica mav be used when there seems to be feeble circulation in the nervous substance and tendency to congestion, manifested 410 DISEASES OF CHILDREN. by symptoms of paralysis, or a feeling of deadness, coldness, or tingling as if the part were asleep. In a large majority of cases, however, there is no lesion that would seem sufficient to occasion the epileptic seizure; and even where there is, and Ave have removed it, and restored all the functions of the system, the nervous disease Avill still continue. Here our treatment will be, to a great extent, empirical; it is true Ave correct all lesions of function, and try to get the sys- tem in as healthy a conelition as possible, but after this Ave give remedies simply because they have proven efficient in other cases. I have employed the bromide of ammonium in my prac- tice, with the most marked success, sometimes using it alone, and at others in combination with other remedies. I prescribe it in the proportion of half an ounce of the salt to four ounces of water, of Avhich the dose is half a teaspoonful four or five times a day. If avc are to expect success, the remedy must be perse- vered with, and if the quantity named is not sufficient, it should be increaseel to such an extent as to hold the paroxysms in check. After tAveuty years experience, I can still-recommend the bromide of ammonium, especially in early life, having cured scores of cases with it. Do ne>t substitute bromide of potash for it, for this remedy has a Avidely different field. If the patient is stout, has a vigorous circulation, and suffers from excitement of the reproductive organs, bromide of potassium is the remedy. Some most persistent cases have yielded to this treatment, and I am in hopes that it Avill prove curative in many of these distress- ing cases. All undue excitement must be avoided in epilepsy, the sufferer leading the most regular life. Some employment should be fur- nished that Avoulel amuse the mind, anel keep it normally active, but much mental exertion is injurious ; novel reading, or any- thing in Avhich the mind becomes deeply absorbed, proves hurt- ful. Above all things else, excessive sexual excitement is most injurious, either as solitary vice or irritation of the organs from disease, and it Avill become the practitioner's duty to examine into the case with reference to this matter, and give the neces- sary advice and treatment. CONA'ULSIONS. 411 CONVULSIONS. Convulsions occur far more frequently during childhood than after puberty, though they may be occasionally noticed at all ages. The causes giving rise to them are various. Sometimes they are produced by disease of the brain and spinal cord, as in determination, inflammation, and se>me obscure structural lesions; at others they arise from an external irritation, it being trans-1 mitteel to the spinal cord, and giving rise to excited reflex action. Ae-e-emling to Dr. Marshall Hall, convulsions are dependent upon irritation of the true spinal system, and though this occurs in some cases from causes acting directly upon the nervous system, it more frequently depends upon an irritation of some distant part transmitted to the spinal cord through the nerves. Thus, Ave find convulsions arising in this Avay eluring dentition, from crude or acrid ingesta, from irritation of the stomach or bowels, from the irritation produced by worms, and from inflammation of internal organs, or disease of the surface, attended with great irritation and pain. Symptoms.—If convulsions occur during disease, they are generally preceded by tolerably Avell-niarkedsymptoms, by Avhich the ch)se observer may anticipate their approach ; and though not always constant it is Avell to give them due consideration. The most marked of these is a sudden, jerking, involuntary movement of the extremities, and quick grasping movement of the hands. This w ill be observed as avcH when the child sleeps as Avhen awake, anel is sometimes increased by motion. Usually the child sleeps with its eves partly open, and Ave ob- serve that the globe of the eye is drawn upward and rolled about, and this involuntary movement of the eye may be fre- quently noticed when awake. AVith these symptoms there may be excitement of the nervous system, manifested by restlessness, fits of crving in children, anel sleeplessness ; or Ave may have the reverse, the patient being dull, impassible and somnolent. The attack is always sudden, the patient losing consciousness, and being to a great extent insensible. The convulsion is usu- ally very marked, but in some cases we find it slight or entirely absent, the patient being rigid and remaining in one position. Respiration is labored, in many cases very markedly so, and in 412 diseases of children. these the countenance is turgid anel purple, and the features distorted. The pulse is very frequent and small, or it is soft, feeble and small, and but little increaseel in frequency. In the severer cases, deglutition is almost impossible, and from the fall- ing backAvard of the tongue respiration is snoring. These symp- toms may continue for* a moment or tAvo to fifteen minutes, or half an hour, in the milder cases terminating in a return of con- sciousness, but the severer in a deep sopor, from which the patient can not be aroused. .One convulsion may terminate the attack, but in many cases one succeeds another for from one to tAventy-four hours. The interval betAveen the spasms is fre- quently marked by nothing more than a relaxation of the entire system, and restoration of the poAver of deglutition, the patient being in a semi-comatose condition, and totally unconscious. Children having convulsions once, are usually more liable to them than others, and they will frequently come on from slight causes. Diagnosis.—The diagnosis of convulsions is very easy, there being no possible chance of mistaking the symptoms. The sudden loss of consciousness, convulsive movement, difficult res- piration, and frequent, small pulse, can not be confounded with any other disease. It is true that Ave can not distinguish betAveen simple convulsions and epilepsy, except by the lapse of time. Prognosis.—The prognosis is usually favorable, though it is very difficult in some cases to arrest the convulsive action. Oc- casionally cases Avill be seen that will prove fatal in spite of treatment. Post-Mortem Examination.—The scalpel reveals no con- stant lesion to account fen* the symptoms. AVhen there has been determination to or inflammation of the brain, Ave of course will find the evidence of these lesions. But Avhen the disease has arisen from an extrinsic irritation, there is not the slightest evielence of disease of the nerves. Treatment.—Our primary object is to arrest the spasmodic movement Avhich is so alarming to the friends, anel, no matter Iioav often seen, to some extent so to the practitioner. Calmness and decision are very important requisites in this case, as all around the patient is excitement, and a hundred expedients to benefit the sufferer are proposed. C.JNVCLSIONS. 413 A quick examination of the patient will enable us to clasify our cases into two groups, and select the appropriate remedy. In the one there is marked vascular excitement, with irritation and determination of blood to the brain anel spinal cord; in the other the circulation is feeble, and the condition is one of atony. In the first case the remedies are sedative, in the second thev are stimulant, If the convulsion passes off so that remedies can be given by mouth, we will add to a half glass of water Tinct, of Aconite or Veratrum (as indicated) gtt. v., Tinct. of Gelseminum gtt. x. to gtt. xxx., and give a teaspoonful every ten or fifteen minutes, until the convulsions are arrested, then less frequently. If there is a markedly pinched expression about the eyes or base of the brain, Rhus Avill take the place of Gelseminum. It is especially indicated by sudden startings and a shrill cry (cry encephalique). If. the patient has been suffering from severe pain, and the convulsions have come on during a paroxysm of it, Ave would give—Py. Hydrate of Chloral oij., syrup, water, aa. 5j., a half teaspoonful or teaspoonful sufficiently often to arrest the convulsions. Sometimes the single dose Avill be sufficient, some- times the child will require as much as a half ounce of the mixture. AA nen the patient is full blooded, and the face and neck are full or red, Bromide of Potassium may be added to the mixture. Asafbetida is a remedy when there has been irritation of the stomach and intestinal canal, with gaseous accumulation. It is a stimulant, anel ought to be classed with the second group, but the gastro-intestinal irritation is the best indication. Of the second group of remedies (stimulants). Lobelia Avill take the first place. It is indicated by an oppressed circulation and respiration, fullness of tissue, and Avant of expression, Avhen the convulsion has passeel off. Frequently Ave prescribe from our pocket-case— Py Tinct, Lobelia Seed gtt. x. to gtt. xx., Avater 5iv.; a teaspoonful every fifteen minutes until the convul- sions have ceased. If Ave have it at hand, the ohl-fashiemed Comp. Tincture e>f Lobelia and Capsicum may be given in doses of half to one teaspoonful, to nausea and vomiting. Sulphuric ether is a gooel remedy in these cases, and may be given in doses e>f ten drops on sugar or in mucilage, anel repeate'el frequently. It may also be useel as an anaesthetic. Chloroform may occasionally be given internally in doses e)f 414 DISEASES OF CHILDREN. ten drops, but I prefer to use it by inhalation. If the convul- sions are severe, with but little interval between them for the administration of-medicines, or if, OAving to their severity, Ave can not see the indications for remedies, chloioform should be used by inhalation to the extent of complete arrest of convulsive action, and continued until Ave are satisfied that we have the case Avell in hand. The indicated remedies should be.given as soon as the patient can SAvalloAV them. One of the best, if not the very best remedy to prevent a re- currence of coiiA-ulsions Avhen they have been arrested, is the bromide of ammonium. Fe>r children I usually prescribe it oij. to Avater oiv., and give teaspoonful doses as often as may be re- quired (usually every three or four hours). It may be given for the arrest of convulsions in some cases Avith most excellent results. AVhen children are inclined to convulsions the preparation of bromide of ammonium should be kept in the house, and its ad- ministration directed when the child shows the slightest symp- toms of convulsive action. As convulsions of childhood will sometimes run into confirmed epilepsy, Ave can not be too much on our guard. I prescribe the remedy-under consideration, and insist that there shall never be any neglect to administer it if indicated. If a hot foot bath can be rightly used, it will be of advantage in many cases; there must be a bucket of Avater, so that the legs maybe immersed to the knees; it must be as hot as the chilel can bear it, and hot water must be added every ten minutes to keep up the temperature, and both child and bucket must be sur- rounded by a blanket or shawl. Thirty minutes is the least time for using the hot foot bath. The sitz bath may sometimes be employed Avith the same pre- cautions, and even a general bath. When, however, there is need of stimulating the skin, the hot blanket pack may be used, or the child may be rapidly sponged with hot water. AVhen the temperature is very high, and the head hot, an enema of five or six ounces of cold water, with a teaspoonful of tincture of lobelia may be given. If there is marked prostration, hot water may be used for this injection and Compound Tinct. of Lobelia and Capsicum added. If Ave are satisfied that the convulsions are due to irritant or crude ingesta, an emetic may be given at once. Ten grains of Ipecac, any preparation of Lobelia, or even salt water, will CHOREA. 415 ansAver our purpose. If Ave have reason to believe that there is irritant material in the intestinal canal, use an enema of Avarm Avater to Avhich Ave have added compound powder of jalap anel senna oss. In the treatment of disease Ave want to notice the symptoms of convulsions Avhen they first appear, that remedies may be selected to remove them. "An ounce of prevention is Avorth a pound of cure," at least it saves us much trouble. Gelsemi- num, Belladonna, Rhus, Lobelia, Apis, Veratrum, Bromide of Ammonium, as indicated, will usually relieve the nervous irrita- tion. The rule may be repeated—"the indicated remedy is the remedy to prevent convulsions." CHOREA This affection, known commonly as St. Vitus* Dance, occurs most generally about the age of puberty, though it sometimes appears as early as the sixth or eighth year, and as late as the thirteenth, and in some cases later than this. It is confined principally to the female sex, but in rare cases it is met Avith in the male. Most generally it is associated with some derange- ment of the sexual organs, anel it is not unfrequently associated with hysteria. AVe usually find it in persons of feeble health, anel precocious mental development, but in some cases, in persons of the. opposite character, in which it may be induced by torpor of the liver and bowels, deranged secretion of the skin anel kid- neys, and from close confinement or sedentary occupations. The modern disease received its name, doubtless, from the dancing manias of the middle ages. The "dancing plague" or St Vitus' dance, commenced in Strasburg, in 1418, and is thus described by Burton : "Chorus Sanctis Viti, the lascivious dance, as Paracelsus calls it, because they that are taken with it can do nothing 'but dance till thcv are dead or cured. It is so called for that the parties were wont to go to St. Vitus for help, and after they had danced there a while they were certainly freed 'Tis strange to hear how long they will dance, and in what manner, over stools, forms, tables; even great-bellied women sometimes (and yet never hurt their children) will dance so Ion- that thev can stir neither hand nor f>ot, but.seem to be quite'dead. One in red clothes they can not abide; mus.c 416 DISEASES OF CHILDREN. above all things they love ; and therefore magistrates in Ger- many Avill hire musicians to play to them, and some lusty, sturdy companions to elau/ee with them." Another form e>f the dancing mania, termed St. John's dance, commenced in 1374, anel exteneled over the greater portion of Europe. "At Cologne the number pe>ssessed amounted to more than five hundred, and at Metz the streets are said to have been filled with eleven hundred dancers. Peasants left their pIoA\s, mechanics their Avorkshops, houseAvives their domestic duties, to join the Avilel revels, anel this rich commercial city became the scene of the most ominous disorder ; secret desires Ave re excited and tAvo often found opportunities for Avild enjoyment; numer- ous beggars, stimulated by vice and misery, aA'ailed themselves of this new complaint to gain a temporary livelihood. Girls anel and boys quitted their parents, and servants their masters, to amuse themselves at the dances of those possessed, and greedily imbibed the poison of mental infection. Above a hundred un- married women Ave re seen roving about in consecrated ami 1111- consecrateel places, anel the consequences were soon perceived ; gangs of idle A-agabonds, avIio understood how to imitate to the life the gestures and convulsions of those really affected, roved from place to place seeking maintenance and adventures, and thus, Avherever they went spreading this disgusting spasmodic disease like a plague; for in maladies of this kind, the suscepti- ble are infected as easily by the appearance as the reality." (Hecker.) This gives the origin of the name of the affection Ave are iioav considering, anel though there is no similarity betAveen the ancient and modern St. Vitus' dance, the description just given illustrates the ease with Avhich nervous affections of this kind may be propagated. And it is a fact, proven by numerous in- stances in hospital practice, that attacks of hysteria, epilepsy, and chorea, will be excited by witnessing the malady in another. As regards the pathology of the affection, Ave must conclude that there is an irritation of the true spinal cord, arising some- times from debility, and at others from extrinsic causes of irri- tation. In either case the excitation of the nervous system is indicative of debility, rather than strength, and in many cases is based upon feeble nutrition of the nerve substance. CHOREA. 417 Symptoms.—The first evidences of chorea are occasional invol- untary movements of the hands and the facial muscles, and an inability to sit quietly in one position. Very frequently the fingers are quickly and involuntarily moved, and when the pa- tient uses the hands it is with a quick unnatural movement. As the disease progresses the involuntary movements become continuous, some part of the body being constantly in motion, and the movements are now very much exaggerated. If the patient attempts to do anything, she seems to have but partial control over her muscles, and while they are being directed to the end intended, they are going through a succession of move- ments entirely independent. So great is this, sometimes, that the patient can not sit still, nor even keep the hands quiet for a moment, and her walking is irregular from the same cause. The facial muscles are sometimes very much involved, and the attempt to speak, or give expression to the emotions, is followed by various contortions of the countenance, which would be laughable Avere they not connected with so serious a malady. Sometimes it is almost impossible for the patient to express her- self intelligibly, owing to spasmodic action of the muscles of the mouth and of the larynx. As before remarked, the general health is usually impaired previous to the commencement of the disease, and this becomes more marked as it progresses; symptoms of anaemia are of com- mon occurrence, the skin being blanched, the pulse feeble, the lips and gums pale, variable appetite, imperfect digestion and constipation of the bowels. The mind is more or'less affected, the patient being low spirited, and desiring solitude the counte- nance being pale, languid and vacant. In some instances con- firmed chlorosis Avill be deA'eloped during the progress of the disease. It Avill be noticed, that the chilel has no disposition to play or to take exercise, anel does not desire to associate with others, but prefers rather to get Avhere her infirmity will not be noticed; the sensitiveness in this respect being sometimes very great, Diagnosis.—Chorea is marked by such distinctive svmptoms that it is easily recognized, the continual partly voluntary and partly involuntary movements not being observed in any other disease. Prognosis.—Though in some cases very obstinate, the disease is almost ahvays curable. It may last for two or three Aveeks, 27 418 diseases of children. or as many months, and in some rare cases for years. Usually it disappears as the general health is improved. Post-Mortem Examination.—In fatal cases the evidences of anaemia are usually very marked, the tissues being very pale, soft and flaccid. The different organs have been found more or less diseased, but these Avere complications and bore no relation to the spasmodic action. AVe Avould expect te^ find lesions of the brain and spinal cord; but except in those cases terminating in general convulsions, or in inflammation, no change of structure has been noticed. Treatment.—Ararious plans of treatment have been adopted, and many remedies used as specifics in this affection, and as is usual, Ave find that Avhere the means are so abundant they are not very efficient. We had much better adopt a rational plan of treatment, by correcting any dyscrasia, and getting a normal perforniance of the various functions of the body, rather than depend upon any one remedy, no matter how highly it is praised. The disease is intimately related to rheumatism in many cases and the remedies will be selected from the class of anti-rheu- matics, to which the reader is referred. Macrotys probably stands first on the list, as it has probably benefited more patients than any other remedy. In some cases it is given alone, in others it may be combined with Aconite or Veratrum, in others Avith Va- lerian, and in still others with Arsenic. One of the best prepa- rations I have ever used is—Py Tinct. Macrotys 5ss., Tinct. Valerian Siss., in doses of five to twenty drops every three hours. AVith Arsenic the prescription Avill be—R/ Tinct. Macrotys 5j., FoAvlers Solution of Arsenic 5ss., water 5iv.; a teaspoonful every four hours. Sticta, Bryonia, Apocynum, and Colchicum, have all been used with good results, as has the iodide of potassium Avhen the tongue is broad and of a bluish pallor. If the disease is associated with amenorrhoea, or irregularity of the menstrual function, this must be attended to. In some cases the emmenagogue pill of the Dispensatory Avill prove use- ful, both as a cathartic and fin- its action on the uterus. The Avilel ginger is another agent that Avill prove useful in some of these cases. The Macrotys, or Cimicifuga, has already been named as a remedy in cases where the patient complains of Avan- dering pains in various parts of the body, or pain in the back CHOREA. 419 and limbs. AVe sometimes associate it with ATalerian or Scutel- laria, and sometimes with the bitter tonics. The extract of Indian hemp has been employed with benefit, in doses of half a grain three times a day, and good results are said to have attended the administration of small doses of Stramonium. The sulphate and oxide of zinc have been prescribed oftener possibly than any other agents, and Ave must believe, from the favorable reports given, that they have an action in these cases ; these remedies may be given, commencing with half-grain doses four times a day, and gradually increased until five or ten grains are admin- istered. If there is tenderness on pressure over the spinal cord, coun- ter-irritation will often prove very efficient, anel the same will be the case Avhen there is tenderness over the epigastrium. Electricity has been frequently resorted to in chorea, and the reports of its action differ materially. AVhen passeel through the limbs it is not only useless, but sometimes positively injuri- ous; but Avhen applied to the spine it is almost ahvays beneficial. The common electro-magnetic battery may be employed, the negative pole being applied to the sacrum, and the positive passed backAvard and fonvard over the spine. The better plan, hoAvever, is to insulate the patient, and by the old-fashioned electric machine, charge the patient and withdraAV the spark from the back. In one case I have employed the bromide of ammonium in addition to a tonic treatment, and seemingly Avith marked benefit. A/ery much Avill depend upon the home management of the patient, All causes of irritation must be carefully avoided, and she should be encouraged to take suitable exercise, and try to control the involuntary movements. Out-door exercise, pleasant company, and something to constantly occupy the mind with, exert an important influence, and it will sometimes be found that where the patient is allowed to have her own way, if not decidedly improper, she will get along better. In some cases the disease results, in both male and female, from sexual excita- tion and onanism; this should be looked into, and if reasonable evidence exists, means should be employed to put a stop to it. The manner of doing this will haA'e to be left to the discretion of the physician, and will vary in different cases. 420 DISEASES OF CHILDREN. TRISMUS NASCENTIUM. Infantile tetanus is of very rare occurrence, and a physician may be in practice a lifetime Avithout seeing a case. It occurs most frequently in the children of the pemr, especially in badly ventilated dwellings, and when the mother and child have had insufficient food, clothing, etc., and a Avant of cleanliness. That it does not ahvays depend upon these conditions, I have evidence in one case that came to my knoAvledge, in a family in comfort- able circumstances. Causes.—The conditions above named may be considered as predisposing causes. The exciting cause is an unhealthy in- flammation of the navel; the disease is, therefore, really trau- matic tetanus. Pathology.—The tetanic convulsion is dependent upon irri- tation of the spinal cord and excess of reflex action. Post-mortem examination shoAvs an inflammatory condition of the unbilical vessels, and of the peritoneum about the umbilicus and reflected upon the artery and A'eins. Examination of the spine sIioavs in- jection of the arachnoid and pia mater, with effusion of serum, lymph, and sometimes of blood. Symptoms.—The disease may make its appearance in a day or tAvo after birth, but more frequently about the ninth day. The child is observed to be restless and fretful, sleeps badly, and has paroxysms of crying Avhich seem like colic. It moves the loAver extremities in a peculiar manner, does not nurse Avell, and has greenish and slimy discharges from the boAvels. These symptoms continuing fijr a time, it is attacked with convulsions, Avhich are, hoAvever, very irregular. "These con- vulsive motions recur at uncertain intervals, and produce vari- ous effects. Sometimes the agitation is very great; the mouth foams; the thumbs are rivited into the palms of the hands; the jaws are locked from the commencement, so as to prevent the action of sucking and SAvallowing ; any attempt to wet the mouth or fauces, or to administer the medicines, seems to aggravate the spasms; and the face becomes turgid and of a livid hue, as do most other parts of the body. From this latter circumstance nurses speak of this form as the 'black fits.' The conflict lasts from eight to thirty hours, and in some rare instances to about NIGHT TERRORS. 421 forty hours; when the poAvers of nature seem to sink exhausted and overpowered by their own exertions." Treatment.—Put the child upon the use of Veratrum and Gelseminum in full doses, as—Py. Tincture of Veratrum o-tt. v., Tincture of Gelseminum oss., Avater 5ij.; a teaspoonful every hour. As it is not very easy to give the entire teaspoonful at once, it may be given in smaller doses through the hour, or the quantity of Avater may be lessened. AVhen the disease is very persistent I should not hesitate to double or even quadruple the quantities of the remedies named. Locally the application of a warm emollient poultice to the abdomen over the umbilicus Avill be found beneficial. Ulmus fulva, flaxseed, or anything of a similar character may be used ; or in place of these, application of a cloth spread Avith the mild zinc ointment Avill answer a good purpose. NIGHT TERRORS. AA7e are consulted occasionally Avith regard to the sudden waking of the chilel at night, manifesting every evidence of ter- ror. Generally it Avakes Avith a piercing scream, and starts up in bed with affright, and it is some minutes before it can Le assured that it is safe, and quieted. There may be but one paroxysm through the night, but occasionally there will be two or three. In some cases it Avill also occur Avhen the child sleeps in the daytime. Many persons think that this groAvs out of frights from play- mates or servants, or fearful stories about ghosts, giants, robbers, etc., Avhich are so frequently tolel to children. AVhile this gives rise to a morbid fear, manifesting itself especially after dark, but also following the person in the day, it has little or nothing to do with this case. In this there is an irritation of the brain with determination of blood, and the night terrors are similar in their cause to con- vulsions and epilepsy, the first being of the cerebrum—the intel- lectual portion, the second of the spinal cord—or of automatic movement. The use of small doses of Aconite Avith Rhus, given in the after- noon and evening, avi'II frequently remove the unpleasantness. In some cases the indications are very clear for Gelseminum and 422 DISEASES OF CHILDREN. Ave use it in place of Rhus. In other cases there is an irritation of the skin associated with the unpleasant dreams, and Apis or Belladonna will come in play. If the child is nervous and sobs in its sleep, Pulsatilla will be the remedy, and it may be given three or four times daily. In some cases Ave will find a torpid condition of the boAvels, Avhich Avill require the administration of a mild cathartic. In some, very small doses of podophyllin, thoroughly triturated and combined with hvdrastia, will be found to answer the purpose well. A tonic and restorative treatment will almost ahvays be neces- sary. Here I would put the child upon the use of our common prescription : Py. Tincture of Muriate of Iron oss., Glycerine gij.; a teaspoonful three times a day ; or the compound syrup of the hypophosphites. PARALYSIS. Infantile paralysis is a very different disease from that Ave are called to treat in the adult. A\Te are accustomed to think of paralysis as a loss of motion or sensation ; in this case there is but diminution of one or both. In slight degree it is met Avith quite frequently, and I have no doubt that it is often overlooked, or attributed to something else. Causes.—It is very difficult to determine the causes of infan- tile paralysis. In most cases I believe there'is a congenital fee- bleness of the nerve centers, and afterward from imperfect nutri- tion the disease is developed. In other cases it is the result of injury to the spine, usually from bad nursing or from a fall. Pathology.—The pathology of the disease is pretty clearly stated above—enfeeblemeut of the nerve centers anel impaired nutrition. I do ne>t think that I ha\Te seen evidence of any other lesion in the cases I have examined. Symptoms—In the majority of cases AATe Avill first notice the difficulty in feebleness of the lower extremities, and an imperfect command over them. Usually one side is principally affected, and the disease seems to be of one or more articulations. I have noticed it oftenest in the hip, and from the eversion of the toes, and shortening of the limb, have felt confident there Avas a paralysis. 423 dislocation. Careful examination, hoAvever, could detect no lesion. In other cases the whole pelvis seemed to be affected, having no strength to support the body, giving a very feeble point of action for the muscles of the extremities. More rarely Ave see cases of paralysis of the upper extremities, yet they are easily recognized by the sameness of the symptoms. The mother thinks the child's arm has been dislocated, or has been injured in some Avay, and attributes the loss of poAver to this. On first looking at the arm, Ave suspett a dislocation, its position is so unnatural and its movements so feeble, but an ex- amination sIioavs the bones in their proper place. Facial paralysis is still more rare, but cases are on record. Paralysis of the third pair of nerves, causing falling of the upper eyeliel, or ptosis, is occasionally seen. Again, a single muscle may be affected, as Avhen from paralysis of a sterno-mastoid avc have torticollis. Treatment.—Of course the treatment Avill be, to some extent, dependent upon the cause, and a careful examination will be in- stituted to determine the lesion which has given rise to it. If from irritation of the stomach and intestinal canal, this should be removed, anel means employed to restore digestion. If worms are thought to be present, the Pe>elophyllin anel Santonine may be given. If from irritation of the urinary apparatus, this must be relieved. Outside of these wrongs, which may be the cause of paralysis, we look to the nerve centers for the Avrong, anel here Ave wi 11 be guideel by the special indications for remedies. Nux vomica will frequently be inelicated, there being evidences of an ■enfeebled circulation. AVith flushed face and contracted pupils the patient will have Gelseminum, usually Avith one of the sedatives. If the patient is dull and inclined to sleep, Belladonna Avill be given ; and with sluggish muscular action, Ergot. Rhus is indicated bv the sharp pulse, frontal headache, and red papillae of tongue; Bryonia by the corded pulse, and flushed right cheek; Macrotys by muscular pain and soreness. Inunction with quinine has been of marked benefit in these cases; even friction with a*fatty matter (lard) is of advantage". Brisk friction to the spine and the part affected, with salt ami water usin be involved in the inflammation, the conjunctiva being injected and thickened. By the third or fourth day, there is a free discharge of yelhnvish purulent matter from the eye, anel the intederanee of light is extreme AVhen the lids are opened the conjunctiva is seen to be much SAvolleu, and many times the chemosis is so great that the cornea can hardly be seen. Continuing in this Avay, the disease may run its course to the destruction e>f the eye in three or four days, or, as in the major- ity eif cases, it will last as many Aveeks, and the child will sloAvly recover. Treatment.—I have great faith in the value of internal rem- edies in disease of the eyes, though the proper local means should not be neglected. Prepare for the child Aconite in the usual doses, with Gelseminum, Rhus, Belladonna, Phytolacca, or Apis, as may be indicated. The child may also be medicated through the mother, if her health is impaired. Not unfrequently the unpleasant coating upon the tongue, the bad breath, and imper- fect digestion, will call for sulphite e;f soda or sulphurous acid. The eyes should be kept free from the discharge (clean) by washing them every two or three hours Avith warm water, to which may sometimes be added a small portion of salt. In some cases the water may be used as hot as it can be borne. To thor- oughly cleanse the eye, the lids may be opened and the water alloAved te) trickle through, to Avash the pus away. A lotion of Aconite or A'eratrum (oj. to 5j.) applied above and around the eyes, anel sometimes to the lids, will give relief. In cases of moderate severity a collyrium may be made by adding Tinct. Belladonna or Gelseminum to Avater. Or in a more advanced stage a solution of atropia may be employed (gr. | te> water 5j.), or an infusion of Baptisia filtered, or a solu- tion of Hvdrastia (Berberin), grs. ij. to Avater Sj. If the case is very serious, and the eye is endangered, nitric acid may be applied to the surface of the lids (everted), using a pine pencil. I think it preferable to the nitrate of silver which is so commonly used in these cases. DISEASES OF THE EYE. 427 DISEASES OF THE APPENDAGES OF THE EVE. i The eyelids may be the subject of phlegmonous inflammation, usually associated Avith erysipelas. They are swollen and livid, and very painful, and occasionally the inflammation extends to the cellular tissue of the orbit. It may terminate in resolution or suppuration, the pain being severe and throbbing Avhen pus has formed, and the constitutional symptoms tolerably well marked. If the inflammation is dependent upon erysipelas, Ave may apply equal parts of tincture of muriate of iron and- glyce- rine, every tAvo or three hours, keeping a cloth Avet with'the same over it ; if from other causes, a poultice of equal parts of Hyelras- tis anel Ulmus, or cloths dippeel in a decoction of Cornus, with a small portion of tincture of Aconite. The boAvels maybe moved with any simple laxatiA'e, and if necessary, a diaphoretic ami diuretic given. If suppuration occurs, the abscess, should be carefully opened as soon as it is detected, as if it remains it in- creases in size, and sometimes causes great destruction. Furuncle, or boils of the eyelid, are of very frequent occurrence, and sometimes occasion much suffering. Occasionally they pass through their stages rapidly, a Aveek sufficing for their removal, but in other cases they are very chronic. AVhen formed on the edge of the eyelid, they are called styes, and are smaller but not less painful. They require but little attention, except in such cases as would be injured by the continued pain and restlessness produced by them. In such cases they may be incised, anel if pus has not yet formed, touched freely with a crystal of sulphate of zinc, and a poultice applied. In such cases lime Avater may be given with benefit, to prevent the recurrence of them. The general health is also improved. In place of lime water Ave may employ sulphide of lime in doses of one eighth of a grain four times a day. Ptosis, or falling of the upper eyeliel, is caused by paralysis of the third pair of nerves, or by disease affecting the eyeliel, or the levator muscle. In cases of paralysis, it may be relieved some- times by the use of electricity or local stimulant applications and the proper internal remeelies; failing in this and in the cases not dependent upon paralysis, a surgical operation is demanded. Entropium or inversion of the eyelids, and cctropium or eversion, are only remediable by surgical operations. 428 DISEASES OF CHILDREN. Trichiasis, or inversion of the eyelashes, is popularly knoAvn as "wild hairs in the eye," and is often a source of great irrita- tion or inflammation. The trouble is OAving te) a misdirection of the cilia, a portion of them being turned iinvarel, so as to come in contact with the eye. The cause is usually easily detected by turning the patient's eye to a strong light and slightly raising the lie], the faulty hairs being seen to pass iinvarel to the con- junctiva. They are usually of a light color, smaller and much more flexible than the normal ones, anel for these reasons are sometimes detected Avith difficulty. In cases of partial trichiasis the treatment is easy, and consists simply in removing the of- fending cilia Avith a pair of forceps. I can yet feel the mortifi- cation I once experienced, in Avhich, after treating a case of "sore eyes" for two Aveeks, the patient was cured in forty-eight hours by an old woman removing these faulty hairs. In severe cases this will not ansAver, a surgical operation being necessary. DISEASES OF THE LACHRYMAL APPARATUS. The lachrymal gland is so protected within the orbit that it is rarely the seat of disease. Inflammation sometimes occurs, and is marked by pain in the region of the gland and dryness of the eye from arrest of secretion. AVhen the inflammation subsides there is usually too free secretion and epiphora, but this soon sub- sides. It should be treated as any other inflammation. Inflammation of the lachrymal sac is of frequent occurrence, and requires care in its management. It makes its appearance usually as a diffused, erysipelatous-like redness and swelling of the parts near the internal can thus, with deep-seated pain, and more or less irritation of the conjunctiva, increased lachrymation and passage of the tears over the eyelid. The inflammation con- tinuing for some days, the parts become much SAvolleu and very painful, and at last pus having formed, it discharges through the integument. In some cases the pus finds its way through the lachrymal canals by pressure, and the inflammation becomes chronic, but Avithout the formation of a fistula. Usually there is closure of the nasal duct, Avhich remains permanent unless an operation is undertaken for its removal, though sometimes the closure of the nasal duct is the primary affection, the inflamma- tion of the lachrymal sac being caused by it. DISEASES OF THE EYE. 429 The child should have the right internal treatment as for any other disease, in the use of Aconite or Veratrum, with Phyto- lacca, Rhus, Gelseminum, Belladonna, or Avhatever remedy may be indicated. If now the part is penciled with Tincture Aconite or Tincture Veratrum in the first stage, or has a Avet dressing of Rj Salicylic Aciel, Borax, aa., gr. x., water Siv., if suppuration is threatened, we usually get along Avell. In some cases the deep redness AviII indicate Tincture Muriate of Iron oj., Glycerine rjss. applieel to the part. If pus forms, an incision should be early made fin* its removal, thus preventing change of the lachrymal sac, and especially distension, and permanent closure of the nasal duct. An injection of ten or tAveuty grains of sesqui-carbonate of potash to the ounce of water, will iioav assist very much in effecting a speedy cure. As soon as the inflammation subsides, if the nasal duct seems closed, a style should be inserted. Closure of the nasal duct, producing fistula lachrymalis, fre- quently results from the above inflammation, though it may be produced by injuries of the bones or soft parts, or an extension of inflammation to its mucous lining from the nose, or from the conjunctiva. In a majority of cases there is a fistulous opening over the lachrymal sac, or a continuous suppuration and dis- charge of pus at the internal canthus, through the puncta, with more or less frequent attacks of acute inflammation of the sac, anel discharge through the integument. In some of these cases a fungous-looking mass of considerable size is found upon the site of the lachrymal sac, Avhich is constantly discharging pus mixeel with tears. This and the constant floAving of the tears over the eyelid, is very unpleasant, and occasionally it keeps up continuous irritation of the eye, and causes imperfect vision. The disease is only cured by an operation, which consists in opening the lachrymal sac and introducing a sih-er style made for the purpose. The usual means to relieve irritation are then made use of, and the style retained until there is evidence of the free passage of tears, and restoration of the mucous membrane lining the duct, when it is removed, and the external opening allowed to heal. The puncta or canaliculi may be obstructed from inflammatory action, and occasionally from other causes. In these cases there is also the overflow of tears and irritation of the lid. If it is produced bv inflammation, the means heretofore named may be used to arrest it. If from other causes an Anel's probe may 430 DISEASES OF CHILDREN. be passed into the puncta and through the canaliculi inte) the sac, with the result of removing the obstruction. The caruncula lachrymal is is sometimes the seat of inflamma- tion very similar to that in ophthalmia tarsi, and by displace- ment of the puncta will produce watering of the eye. It some- times gives rise to considerable uneasines and pain. It may be treated in the same manner as the other inflammations named, but Avhen persistent is best removed by the use of the mild zinc ointment, or ophthalmic ointment, Occasionally they are the subject of chronic enlargement, forming a reel, soft, tuberculated tumor, of considerable size, which bleeds readily on pressure. It may be occasionally removed by the application of a saturated solution of tannic acid, or the solid nitrate of silver, but in many cases will have to be excised, one-half or more being cut away, the remainder disappears. PTERYGIUM. This is strictly a disease of the conjunctiva, and consists of a thickening of a circumscribed portion of it extending between the internal canthus and the cornea, though occasionally it is found on the temporal side. It is divided into two kinds, the membranous and fleshy, both kinds being triangular, with the apex toAvard the cornea. It commences from Avithout, and groAvs iiiAvard, occasioning but little disturbance until it reaches the cornea. If it commences to involve the conjunctiva-cornea, it gives rise to irritation, and may be attended with serious conse- quences. It may be arrested by cauterizing with nitrate of silver, nitric acid, or other escharotics, but the easiest plan is to dissect off the half next the cornea, when the remainder will generally disappear Avithout trouble. OPHTHALMIA TARSI. Inflammation of the edges of the eyelids is noticed more fre- quently in children than in the adult, and is frequently associated Avith some depraved habit of body, as scrofula. AVhen primary, it may be the result of cold, smoke, impure air, or filthiness; but it is most usually a sequence of catarrhal ophthalmia or scrofu- lous conjunctivitis. The disease is located in the edge of the lid and meibomian follicles, and in many cases so affects the roots of the eye-lashes as to cause them to fall out, hence that appear- OPHTHALMIA TARSI. 431 ance termed "blear-eyed." The eyes look sore and tumid, and the patient complains of a sensation of roughness, anel as if there were sand in the eye, when the lids are moved, and thus there is the constant tendency to keep them partially closed. They are agglutinated te>gether in the morning, sometimes so much so that the patient has to soften them before he can open them, and it is even then attended with pain. Ophthalmia tarsi is essentially a chronic affection, with but little tendency to spontaneous recov- ery, anel is sometimes A-ery difficult to cure ; and if the meibomian glands are closed, the edge of the lid has a shining, glistening appearance. Treatment.—As there is almost ahvays a faulty constitution, with marked evidence of some cachexia^Ave find it important to put the patient upon an alterative anel tonic course of treatment. The compound tincture of Corydalis, or compound syrup of Stil- lingia, Avith iodide of potassium, may be administered in the usual doses. Some preparation of iron should be given with this,—frequently the tincture of muriate of iron Avill answer best,—and if necessary, the bitter tonics may be added. Once in a Avhile cod-liver oil is of advantage, and occasionally we give our patient Fowler's solution of arsenic, with Phytolacca. Very much depends upon keeping the eyes clean, and remov- ing the tenacious secretion without causing pain anel irritation. Hence the eyes should be frequently bathed eluring the day with warm Avater, or a Aveak decoction of Cornus or Hydrastis, keeping them as entirely free from the secretion as possible Glycerine answers a very good purpose in some cases, usually combined with an equal quantity of rose-water, and applied freely. The parts being perfectly cleansed, Ave apply once or tAvice daily, a very small portion of mild zinc or ophthalmic ointment ; or, instend of this, Ave may use a mild collyrium of sulphate of zinc or borax, or one or tAA'O drachms of nitrous ether and vin- egar in eight ounces of Avater, and followed by the glycerine lotion. The application I now place most dependence upon is the brown citrine ointment, one part to two or three parts of simple cerate. In very severe cases, the faulty cilia may be re- moved, the crusts carefully taken off, anel the ulcers lightly touched with nitrate of silver. In the application of warm water, or the decoctions named, or to foment the eye, we can ac- complish our purpose best by the use of a very soft sponge. 432 DISEASES OF CHILDREN. Counter-irritation to the nape of the neck, or behind or before the ears, with the blister or irritating plaster, is often of great advantage. CATARRHAL CONJUNCTIVITIS. The conjunctiva covering in the globe of the eye, and lining the lids, is exquisitely sensitive, and though abundantly protect- ed, is frequently exposeel to the causes of inflammation. Tempo- rary inflammation is often seen as the result of dirt or sand in the eye, or even expe>sure, but very soon disappears Avith rest. The disease we are iioav describing may arise from cold, sudelen changes of temperature, extension of inflammation from the mucous membrane of tne nose, or from inoculation with the secretion of a diseased eye. This last cause should be carefully guarded against, as Ave not unfrequently observe Avhole families attacked Avith the disease from the indiscriminate use of toAvels. Symptoms.—The disease commences Avith a sensation of dry- ness and smarting of the eyelids, Avith a feeling as if dirt or sand had got into the eye, and it is with difficulty that the patient gives up this idea, the impression is so strong. In a slmrt time the eyes seem tumid and SAvolleu, the unpleasant sensations have increased, and a more or less abundant secretion, sometimes opaque and puriform, is established. If the eyes are now exam- ined, the palpebral conjunctiva will be found red, and swollen, and more or less reticular redness of the ocular conjunctiva. As the inflammation progresses, the last portion of the conjunctiva becomes more completely involved, and Ave sometimes observe ecchymosis or extravasated blood under it. In a still severer form the conjunctiva is remarkably injected and swollen to the point Avhere it passes into the cornea, so much so occasionally as to partially cover up this part of the eye; this swelling is termed chemosis. Catarrhal ophthalmia is frequently periodic, the exacer- bation ahvays occurring in the evening, and sometimes attended Avith headache ; the pain and itchiness cease a short time after going to bed, and the patient sleeps well, but it re-appears in the morning on attempting to use the eyes. In many cases the disease continues thus for a Aveek or ten days, and then gets Avell Avithout further change; but in some cases it is more persistent. Sometimes Ave notice a small blister CATARRHAL CONJUNCTIVITIS. 433 on the ocular conjunctiva, which rupturing forms an ulcer, constantly 'lu'enving off an abundant puriform secretion; it may attain the size of a half-dime, or be even larger than this, and is usually very painful. The cornea is sometimes obscured and hazy from the inflammation, and in that variety eff the disease termed phlyctenular has a tendency to ulcerate. This last form of the disease occurs most frequently in children and young persons, and is usually connected with a scrofulous constitution. The symptoms are, marked pain and intolerance of light, free secretion of tears, deep redness of the eyeliels, but slight of the ocular conjunctiva, sometimes but three or four vessels being seen to pass across to the cornea. Soon Ave notice the produc- tion of one or more blisters on the cornea, Avhich discharging, forms an ulcer; this may inprease in size until it involves a con- siderable portion of the cornea, or it may rapidly increase in depth until it perfe>rates it, anel causes a discharge of the aqueems humor. In some of these cases, the phlyctenula are absorbed, leaving a small, Avhite spot, called albugo; or a cicatrix results from the ulceration; called leucoma. If the ulcer penetrates the cornea, the iris is almost always throAvn forward by tfie escape of the aqueous humor, and passing into the opening becomes adherent, and is termed synechia anterior. Diagnosis.—Catarrhal conjunctivitis is usually recognized Avith ease; the inflammatory action commencing in the palpebral con- junctiva, and subsequently extending te> the ocular portion, Avith secretion of muco-pus, are the characteristic symptoms. In phlyctenular ophthalmia, there is inflammation of the conjunc- tiva, but the disease is principally confined to the cornea ; the appearance of the small vesicles or ulcers in the cornea marks the distinction. That form described as pustular, is marked by the formation of pustules, terminating in ulcers in the ocular conjunctiva near the cornea. Prognosis.—In the milder forms of catarrhal ophthalmia Ave usually succeed in arresting the disease in a Aveek or ten days, but if alloAved to progress or badly treated, it may endanger the integrity of the eye and last for months. The phlyctenular form is more difficult to treat and not nnfrequently leaves the marks already mentioned. Pustular ophthalmia is usually very perverse, but Avith care may be managed so as to leaATe no bad 28 434 DISEASES of children. result. Either of these forms may become chronic, and develop structural change which will impair vision to a greater or less extent, Treatment.—The treatment of inflammation of the eyes Avill be conducted on the same general principles that govern our therapeutics in all forms of inflammation. Though the part in- volved is but small, it requires exactly the same general means as if it Ave re an entire lung or other large organ. Remedies, also, will be found just as definite in their action, and as prompt in arresting the inflammatory process. The patient has the indicated sedatives, Aconite or Veratrum gtt. v. to a half glass of Avater, a teaspoonful every hour. Other remedies are given according to the indications. Rhus if there is burning pain in the eyes, or sharp pulse with frontal headache ; Gelseminum if there is flushed face and active circulation to the brain ; Belladonna if there is dullness and capillary congestion ; Bryonia if there is tensive pain in the eye and through the orbits; Apocynum if the lids are markedly swollen (oedematous); Phy- tolacca if the cervical glands are involved or there are phlyc- tenular Occasionally a very foul tongue with sense of oppression will call for an emetic, or full veins and full tissues generally will want Podophyllin. The simple pallid tongue wants a salt of soda; the broad, pallid, dirty tongue, sulphite of soda; the red dirty tongue, sulphurous acid. In malarial regions the frequent necessity for antiperiodics will be noted, and many times they will serve quite as good a purpose as in other diseases with periodic complications. I have seen a conjunctivitis arrested in a couple of days with quinine alone. In some cases Alstonia will prove a good remedy. When antiperiodics cannot be given by mouth, quinine can be used by inunction. The first five days the patient should be kept in a darkened room, and when exercise is taken, the eyes should be well shaded. It is of especial importance that the nervous svstem be kept quiet, and fret fulness and crying prevented ; this will re- quire considerable care and management upon the part of the mother. Various collyria are recommended, in fact so many that the young practitioner does not know which to select. B> Atropia OPACITY OF THE CORNEA. 435 gr. J, Avater 5j. ; R Sulphate of Morphia grs. ij , Aromatic Sul- phuric Acid gtt. x., distilled water 5ij. ; or R/. Tincture of Bella- donna gtt, x.; Tincture of Gelsemiiuun 5ss., Avater §ij.; dropping it in the eye every three or four hours. Associated with this, if the case is acute, I direct that the eye be fomented with hot Avater, a piece of very soft sponge being used to make the appli- cation. In some cases a poultice of equal parts of Hydrastis and Ulmus, answers a good purpose, but I uoav prefer the fomen- tation. In all cases the patient should be kept perfectly still, in a darkened room, and use a light and easily digested diet. Mackenzie strongly recommends the use of a solution of nitrate of silver, gr. iv. to water 5J.; a large drop being applied to the eye tAvo or three times daily. For a few minutes the eye feels easy, and then for ten minutes there is a sharp pricking pain, which subsiding leaves the eye almost free from pain for five or six hours, Avhen the application should be repeated. Dr. AVilliams recommends a solution of sulphate of zinc in rose-AArater in the proportion of from tAvo to four grains to the ounce. OPACITY OF THE CORNEA. Opacities of the cornea are distinguished by different names, according to their density and the character and situation of the lesion. Nebula is the slightest degree, anel is most generally situated in the superficial layers, though occasionally deep seated ; sometimes it is general, and is the result of pressure, or of serous effusion into the substance of the cornea. Albugo is that form of opacity in which the spot has a pearly appearance, and generally results from effusion of plastic lymph in the anterior layers of the cornea. It usually results from the phlyctenula which have receded Avithout bursting. Leucoma is an opaque cicatrix closing an ulceration; it has usually a contracted and circumscribed appearance, and is depressed in its center. Treatment.—"All the three kinds of speck—nebula, albugo anel leucoma—have a natural tendency to disperse as soon as the disease giving rise to them subsides or is removed, and whether they depend on primary inflammation, spreading to the cornea, or secondary inflammation of that part arising from the irritation of inverted eyelashes or granular conjunctiva. AAre must, then, in eA'ery case, endeaA'or to reniOA'e the ophthalmia or the 436 DISEASES of children. mechanical irritation on which the opacity depends, assured that if we succeed in this, nature, by the pre>cess of absorption, will accomplish the Avhole amount of recovery Avhiem is possible. In children and young person.-; many very dense anel extensive opacities are removed in the natural process e>f growth, Avhich Avould be quite immovable in adult life." (Mackenzie.) Patience and perseverance are the great" elements of success in these cases, and abundant time, from three months to as many years, is necessary to the accomplishment of the purpose. The inflammation should be entirely removed in the manner hereto- fore named, and if the person is scrofulous this should be coun- teracted as much as possible and the general health improved. Frequently this is all that is necessary, the opacity disappearing as the inflammation is removed. If after this Ave deem it neces- sary, we prescribe a mildly stimulant collyrium, as wine of opium, pure or diluted ; Common salt grs. ij. to grs. x., to Avater 5j.; or a solution of sulphite of soda grs. ij. to grs. v., to Avater 5j- Sulphite or sulphate of soda, very finely powdered, a small portion dropped in the eye once or twice a day, is some- times an excellent stimulant, and the eye clears up under its use. In other cases, all that is necessary is to give nature sufficient time to remove the deposit; and to prevent injurious meddling with the eyes, we will in these cases prescribe some mild and grateful application simply to occupy the attention of the patient and prevent discouragement. CHAPTER XI. DISEASES OF THE EARS. Disease of the ears is of more frequent occurrence in the child than in the adult; and partial deafness, annoying the person for a lifetime, frequently has its origin in early life. Some of these affections are marked by prominent symptoms, while others are very obscure, and run their course many times without being recognized. Diseases causing structural change arise mostly from two causes—the scrofulous constitution, or an impairment of the DISEASES OF THE EARS. 437 blood folloAving the eruptive fevers. In either case the consti- tutional disease must be recognized, and remedies directed to it, if Ave are to expect success. The symptoms of disease of the ears are those of unpleasant or painful sensations, discharges from the ears, and deafness. The infant expresses its suffering in these cases by frequent move- ment e)f the head, carrying the hand to the affected part, rubbing the side of the head on the pillow, or the mother's arm, and a peculiar contraction of the facial muscles of that side. If there is pain, as from neuralgia or inflammation, the child is restless and fretful, crying out swldenly and piercingly, and at an advanced age sobbing during sleep. Examination of the Ear.—The majority of persons fail in their examination of the ear from defective light, or the Avant O 7 of ability or means to use it. I have seen professed aurists make the "most lamentable failures here, though Avorking Avith fine and costly apparatus. The means are very simple, as is the use. AVe require sun- light or a good lamp, an ordinary toilet mirror, and an ear speculum. Of the last there are several kinds, and most persons avIio use them express a preference for the simple silver cylin- ders, which come in nests of two or three. I like the old-fash- ioned bivalve, as being most readily employed, and adapted to all ages and conditions. If Ave have sunlight, the patient is placed so that the ear to be examined is from the light, the head at such level that the rays may be readily thrown from the mirror to the ear. The speculum is then introduced, and held with one hand, while with the mirror in the other Ave catch the rays of light and throAv them to the bot- tom of the meatus. If Ave use a lamp, it is set on a table by the patient's head, the mirror being employed as before to concen- trate the light and throw it into the speculum. The advantages of this method are tAvo-fold. First, Ave em- ploy a larger volume of light, and have greater command over it, directing it where and as Ave choose. In the second place, Ave are able to see the parts without interposing our head between ' the ear and the light. Those avIio employ the ophthalmoscope or the laryngoscope, may use the perforated mirrors of these instruments as reflectors. There is no difficulty with these means of making a thorough 438 diseases of children. examination of the ear, even in the child, and of determining tht> condition of the external auditory meatus, and membrani tym- pani. FOREIGN BODIES IN THE EAR. Children more frequently than the adult, get foreign bodies in the ear. Often a pea, bean, grain of corn, or other material, will be introduced purposely by the child or some companion in play. Rarely an insect or other living thing accidentally gains en- trance, and causes considerable disturbance. The foreign body does not at first produce any or but little unpleasant feeling, but the efforts at removal, very often rough, excitee^the sensibility of the organ, and after a time excite an ex- treme irritability. The history of the case is plain, and a slight examination determines the presence of the body. Treatment.—There are two methods of removal, both goexl, Avhich Ave choose to suit the particular case in hand. The one is, to take a wire, and bend it upon itself, forming a loop, intro- ducing this by the side of the object until it has passed clearly beyond. Then separating the strands of Avire, they are drawn gently forward, anel catching the object in the loop, it is with- drawn. It is the old plan of removing a cork from a bottle. The other plan is to remove the foreign body by a jet of Avater thrown from a syringe. Taking an ordinary hard rubber or glass syringe of small size filled with warm Avater, the jet is thrown in the ear Avith some force; the rebound causes the de- tachment and removal of the body. It is better that the child's head be placed in such position that the ear will be dependent. Under no circumstances shoulel we undertake to remove a for- eign body with a scoop, forceps, or like instruments. EARACHE. Earache may not strike the reader as being worthy of much study, as the term has little of medical terminology, and smacks of the nursery. The ache, however, is a very troublesome real- ity, producing a very unpleasant commotion in the household, and demanding speedy relief. Causes.—The cause of this neuralgic pain in the ear is mort frequently cold, though it may be, in part, from derangement of the digestive organs and arrest of secretion. DISEASES OF THE EARS. 439 Symptoms.—The chilel is very restless and uneasy, moves its heael from side to side, sleeps but little, and Avakes Avith a start, crying loudly. The pain is undoubtedly paroxysmal in character, as, for a little time, the child is easy, and then breaks out in a piercing cry, as if hurt. Sometimes there is slight febrile action with suffused eyes, Stopped nose, anel other evidences of cold. In some cases the child's face is flushed, anel the temperature of the affected side increased; but at others the face is pallid, the eyes dull, and the patient evidently depressed. An examination of the ear determines Avhether it is neuralgia or inflammation. If the first, there is no SAvelliug, or evidence of structural change, Avhile in inflammation, the swelling, red- ness, heat, and tenderness on pressure, are prominent symrv- toms. Treatment.—AVhen there is excitement of the circulation, I put the child upon the use of tincture of Aconite in the usual doses, adeling Gelseininuni if there is much irritation of the 7 O nervous system, or Rhus if there is the contraction about the eyes, anel the sharp stroke of the pulse. If, on the contrary, there is dullness, the face pale, the pupils dilated, and evidently a sluggish circulation, Belladonna should be used Avith the OO 7 Aconite. In the last case a full dose of quinia once or tAvice daily, will be an important addition to the treatment. As a local application I generally prescribe: R/ Tincture of Aconite, Tincture of Opium, aa. 5ij-, Glycerine Sss.; mix. AVarm a spoon and from it drop one or tAvo drops in the ear, and also apply it around the ear Avith the finger. A Avarm flannel ap- plied over the ear will complete the treatment. OTITIS. Quite a number of different affections have been grouped to- gether under the head of Otitis, and as they are all inflamma- tory, present similar symptoms, and require nearly the same treatment, it Avill hardly be worth while to endeavor to make the distinction. Inflammation of the external auditory meatus anel cavitv of the tympanum are usually produced by sudden changes of temperature, though it may be caused by the introduction of irritants, or even from accumulation of cerumen. 440 DISEASES of children. Symptoms.—Inflammation of the external auditory meatus commences Avith a feeling of stiffness, fullness, and uneasiness about the meatus, which is increased Avhen the ear is pressed upon. In a short time the pain becomes very severe, is tensive, darting, lancinating, and seems to affect the entire side of the head to some extent. Frequently there are marked chilly sen- sations with the accession of the severe pain, and these are fol- lowed by febrile reaction. On examination Ave Avill finel the lining membrane of the meatus tumid and red, sometimes savoI- len so as almost entirely to close the opening. The pain contin- uing for from tAvo to six days, secretion takes place, or pus is formed and discharged, sometimes in considerable quantity. At first it is usually thick, but at last is thin, and in some cases is secreted in very large quantity. The discharge continuing for a short time, the symptoms of inflammation entirely disappear, and the part is restored to its normal condition. Acute inflammation of the cavity of the tympanum is a far more serious affection, anel may result in permanent impairment of the hearing, or even in death by extension to the brain. In children this is usually very severe at night, with comparative ease during the day, though the child is restless and irritable. There is usually considerable fever at night, and even during the day the skin is dry and the pulse hard. Diagnosis.—Inflammation of the ear presents such marked symptoms that it is not easily mistaken. The severity of the pain and its location, and attendant constitutional disturbance, are sufficiently characteristic. If the external meatus is the seat of the disease, it will be found red and SAvollen, as is the case if the membrana tympani is affected. If confined to the cavity of the tympanum, all the symptoms are more severe and there is an absence of external signs of inflammation. AVhen the inflam- mation extends to the mastoid cells, the constitutional disturb- ance is very marked, and Avhen pus forms, the deep throbbing and marked disturbance of the brain show the character e>f the lesion. Prognosis.—Though quite painful, inflammation of the ex- ternal meatus is not dangerous, nor attended with worse results than otorrhoea in occasional cases/ If the tympanum is affee-teel there is some danger of affection of the brain, and considerable otitis. 441 of impairment of the hearing. Inflammation of the mastoid ce.Is, it it progresses to .suppuration, is always dangerous. Treatment.—Put the patient upon the use of Aconite or Veratrum in the usual doses, aiding the action by the use of the hot foot-bath. If there are indications for other remedies these may be added to the seelative solution, or given in alternation. AA e Avill thus find in different cases indications for Gelseminum, Rhus, Bryonia, Belladonna, Apis, Macrotys, Phytolacca, Apocy- num, etc. In some cases—a full tongue heavily coated—emesis Avill give the speediest relief. If the tongue is pallid and dirty, give sulphite of soda; if red and dirty, sulphurous aciel. Locally we may apply the lotion of Aconite and Opium, here- tofore named, around the ear, anel even drop it into the ear. This may be followed by the use of the vapor of Avater, anel hot fomentations of Stramonium. Occasionally much relief is obtained from the use of a lotion of equal parts of tincture of Aconite and Belladonna, applied around the ear. In some cases, the fever being very intense, Ave may employ the vapor of tinc- ture of opium, stramonium, lobelia, tobacco, etc., directly to the external meatus anel membrana tympani, by means of a gutta- percha tube. Chloroform and ether may be used in the same Avay, as may also carbonic acid gas. AVith throbbing pain in the ear, Ave are satisfied that suppura- tion has occurred, anel sometimes an inspection of the meatus Avill sIioav the yelloAvish color of pus. The little abscess should be at once opened with a sharp-pointed bistoury, when Ave Avill have immediate relief. If the disease is of the middle ear, and the pain becomes tensive and throbbing, avc may be satisfied of the presence of pus. An examination of the ear will show the membrana tympani pushed outward (convex) anel blanched and yelloAvish. If it is now incised with a small tenotome, or small, sharp-pointed bistoury, the escape of a drop or tAvo of pus gives relief. In place of destroy- in"- the tympanic membrane by incision, Ave frequently preserve it, for the continuous presence of pus would cause its entire de- struction, and sometimes the destruction of the internal mem- brana, whilst if the pus is discharged, the inflammation ceases, and the wound closes up, the membrane showing but a slight cicatrix. 442 DISEASES of children. If the disease seems to extend to the mastoid portion of the bone, I should apply a blister immediately over it, and follow it with the irritating plaster. In some cases, suppuration having undoubtedly taken place, and dangerous symptoms occurring, it becomes necessary to open into the mastoid cells through the bone, in order to permit the escape of pus. 0 T O R R H (E A . Purulent discharges from the ear may be occasioned by chronic inflammation of the external meatus, or disease of the bony canal, or it may proceed from chronic inflammation of the tym- panum, or disease of adjacent parts, the membrana tympani having been ruptured or destroyeel, so as to permit its escape. In either case there is more or less deafness, uneasiness in the ear, and an offensive discharge The most frequent causes of otorrhoea are inflammation attending the eruptive fevers, injuries, the direct action of cold, and chronic inflammation resulting from acute attack. Some families seem to have a predisposition to this affection, the majority of their children having such dis- charge. In such cases it is almost ahvays associated Avith scrofula and feeble vitality. Otorrhoea from disease of the external auditory meatus is the nmst frequent form of the affection, and might properly be called chronic catarrh. It is of frequent occurrence after scarlet fever and measles, and is often seen in infancy or up to the age of tAvo or three years, becoming more rare as Ave advance to adult age, except in the cases named. It is true, that the disease com- mencing at the age of two or three years may continue through life, but this is not very common when the patient has sufficient vitality to reaeeh adult age. Further than the discharge from the ears of an offensive purulent matter, and some dullness of hearing, there are no prominent symptoms, if we except the al- most invariable cachectic appearance of the child. On examin- ing the ear, Ave will find the bone in a carious conelition. AVhen the hearing is much affected, Ave Avill find the membrana tympani opaque, and its dermoid layer thick and vascular. In some cases the discharge is produced by a small polypoid formation in the ear, and in others by a hardened cerumen. Otorrhoea from disease of the middle ear occurs only when the membrana tympani has been destroyed or ruptured, and may 0T0RRHC3A. 443 arise from chronic inflammation of the lining membrane, disease of the ossicles, or disease of the bony walls. It is most generally the sequence of acute inflammation, which terminating in sup- puration, the membrana tympani gives way, and the inflamma- tion gradually assumes the chronic form. There is always deaf- ness, sometimes but slight, at others marked. There may not be pain or unpleasant sensations in the ear, though usually if there is but a slight opening in the membrana tympani it occasionally becomes closed, and dizziness, ringing in the ear, etc., result from the pressure of the retained secretion. The condition of the tympanum varies greatly; in some cases there is but slight,change of structure, in others the ossicles be- come diseased, and are cast off, the mastoid cells and eustachian tube are affected to some extent, and the hearing is nearly en- tirely destroyed. It may occasionally terminate fatally by an extension of the inflammation to the membranes of the brain. Treatment.—In all cases it becomes necessary to pay atten- tion to the general health, for as long as the child or adult con- tinues cachectic, or sIioavs evidence of a Avrong of the blewd, it is almost impossible to arrest the discharge. The use of lime Avater, sulphite of soela if there is eczema, sulphurous acid, cod liver oil, arsenic, iodide of potash, Donovan's Solution, Phyto- laca, and some of the vegetable alteratiATes, are suggested. It is impossible to name a remedy Avhich will be good in all cases, for here, as in other diseases, the remedy Avill be selected according to the special indications in the case. Prominent among external applications in all forms of this affection, except Avhen occassional by a foreign body lodging in the ear, or a polypoid growth, is counter-irritation over the mas- toid process. It shoulel rarely be neglected, but pursued stead- ily until the cure is complete. The best agent that I have em- ployed is the cantharides, which may be repeated sufficiently often to keep up a continued influence. In common chronic inflammation of the external meatus, washing the ear out thoroughly with tepid Avater, and dropping three or four drops of—Py Tinct of muriate of iron oij., glyce- rine 5J., into the ear once or tAvice daily, will effect a cure in one or two weeks. In place of this, nitric acid gtt. x., to Avater and glve-crine aa. f*>ss., may be employed with advantage. A Aveak solution of thymol, of sulphate of zinc, or acetate of lead, 444 DISEASES of children. from four to ten grains to the ounce of water, may be used in some cases. Py Chlorate of potassa, gr. xx., glycerine 5ss., water 5j., also forms a good application. An infusion of Hama- melis, Hydrastis, Cornus, Geranium, Sage, etc., is found use- ful in some cases. Occasionally I have employed oxide of zinc gr. x., rubbed up with glycerine gss., adding a small portion of morphia if necessary, to relieve irritation. Failures in these cases Avill frequently depend upon a"faulty use of local means. AVhen injections are used they do not reach the affected surfaces. In place of the syringe, a long camel's hair pencil may be used to clean the ear first, and afterward to carry the local remedy close to the membrana tympani if neces- sary. This Avill be readily done by twirling the pencil between the fingers as it is introduced. In some cases the brown citrine ointment, with one to three parts of cod liver oil or simple cerate (according to the soreness), may be applied to the entire diseased surface by twisting a soft piece of cotton cloth, smearing it Avith the ointment, and tAvist- ing it as it is pressed- into the meatus. In other severe cases, nitric acid applied lightly with the pine pencil, will be found a most excellent plan of treatment. If the tympanic cavity is the seat of disease, Ave Avill pay espe- cial attention to the general health, and keep up continuous counter-irritation near the ear. Cleanliness is of prime impor- tance, and hence the ear should be thoroughly Avashed out, once or twice daily. This may be followed by some of the lotions above named, being careful that they are brought in contact with the diseased surface If the discharge is produced by accumulations of hardened cerumen acting as a foreign body, this should be softened and removed with a scoop. If from a polypus, and it is not red and vascular, it may frequently be removed by the application of a saturated solution of tannin, or the careful application of chloride of zinc. The best plan, hoAvever, in all cases, is to catch it with a strong pair of ring forceps, and detach and remove it. DEAFNESS. Partial loss of hearing depends upon various causes, some of which are remediable ; total deafness depends upon disease of the internal ear, and if of any considerable duration is incurable. DEAFNESS. 445 \\ e Avish, therefore, in this place, to inquire into the causes eff partial deafness, and see how fi.: they are amenable to treatment. A\ e may sum them up, as: 1st, from disease of the external meatus; 2d, from disease of the membrana tympani; 3, from disease of the tympanum ; and, 4th, from disease of the eusta- chian tube. Diseases of the internal ear are beyond our powers of diagnosis, though Ave are able occasionally to determine Avith considerable certainty that the deafness is dependent upon par- tial paralysis—Ave call this nervous deafness. The ear-specu- lum shoulel ahvays be used, so as to make an accurate diagnosis. 1. The external meatus suffering from chronic inflammation will give rise to hardness of hearing, as we have already seen. In other cases the lining membrane is thickened and dry, and in addition, the ceruminous glands seem to pour out a very in- spissated secretion, Avhich desiccating sometimes fills up the bot- tom of the meatus. In this case Ave Avould use injections of tepid Avater and the scoop, to thoroughly cleanse the ear, anel then use the lotion of tincture of muriate of iron and glycerine, heretofore mentioned. The lotion of thymol and glycerine may also be used in these cases. If there is irritation of the struc- tures, much benefit will be derived from counter-irritation over the ear. Polypi obstructing the meatus should be removed, as before mentioned. 2. A condition of chronic inflammation of the membrana tympani, giving rise to a fleshy vascular appearance Avhen ex- amined with the speculum, is sometimes a cause of deafness; quite frequently it is associated with catarrhal inflammation of the meatus, though it may persist aftenvard. An injection of a decoction of Cornus and Hydrastis, and the local application with a camel's hair pencil of the oxide of zinc, morphia, and glyce- rine, heretofore named, is usually sufficient. Counter-irritation over the mastoid process is also employed. Relaxation of the membrana tympani is not of frequent occurrence, but may occa- sionally be met Avith as a cause of deafness. It is readily de- termined by the use of the speculum, the membrane being re- markably concave on its external face, and is diagnosed from the same appearance resulting from closure of the eustachian tube, by its being thrown outward by swalloAving with e-loM(l nostrils. Pond's Hamamelis and glycerine, equal parts, make a good local application. Tincture muriate of iron oj. to glyce- rine Sj. maybe used in some cases, and a solution of Hvdrastia, 446 DISEASES OF CHILDREN. gr. ij. to rose-water 5j., Avill give tone to the structures in others. Perforation of the membrana tympani is a frequent cause of deafness, and is readily detected with the speculum. It seems, however, that the deafness depends in part upon thickening of the mucous membrane of the tympanic cavity, for Avhen this is marked, the patient can hardly hear at all, while in other cases the deafness is but slight. AVe should therefore endeavor to re- 1 move all irritation by the use of counter-irritants and appropri- ate local applications, and Ave will then have placed the patient in the best condition for the use of the artificial membrana tym- pani ; this is formed out of vulcanized rubber, and has been very successfully employed. 3. Various changes in the tympanic cavity, resulting from in- flammation, may be the cause of deafness, but there is only one, so far as Ave know, that can be reached by remedial measures. AAre have already noticed that a chronic inflammation of these structures might continue for years, attended with secretion ; and examination shoAvs us in some cases, a thickening of the lining membrane, Avith increased vascularity. In these cases, the persistent use of counter-irritation and the local means here- tofore named will do much toAvard the relief of the deafness. 4. Obstruction of the eustachian tube ahvays gives rise to partial deafness, though, as the causes are usually temporary, the deafness is not of long duration. Dr. Toynbee notices three points of obstruction : 1, at its faucial orifice, a thickening or relaxation of the mucous membrane; 2, at its tympanic orifice, from thickening of the mucous membrane, or a deposit of fibrin ; 3, in the middle part of the tube, from a collection of mucus, a stric- ture of the osseous or cartilaginous portions, or membranous bands connecting the Avails. If the eustachian tube is impervious, Ave will find the membrana tympani sunken in, of a dull, leaden hue, and its surface unnaturally glossy, and SAvalloAving with the nose closed or forcible expiration Avill not have any effect on it. If the patient has had disease of the tonsils, fauces, or poste- rior nares, Ave may reasonably suppose that the disease has been caused by this, and is at the faucial extremity of the tube. The inflammation sometimes extends to the mucous membrane linincr the tube, and its tumefaction causes the disease. In other cases the swelling of the mucous membrane at the termination of the tube, is the cause of it, and in another class it results from re- DEAFNESS. 447 laxation. In these cases, appropriate measures to relieve in- flammatory engorgement in the one instance, and to remove the atony anel relaxation in the other, shoulel be adopteel. The ori- fice of the eustachian tube may be reached through the mouth or inferior meatus of the nose, and local applications may be made Avith a probang or syringe. In some cases it is proposed te) remove obstructions by means of a probe passed into the eustachian tube, but no permanent benefit results from it. AVe may, hoAvever, introduce a catheter, for the purpose of using an injection into the tube, using the same remedies that Avould be indicated in other situations, as, for instance, those recommended in otorrhoea. Nervous Deafness.—Toynbee remarks that "As some cases of deafness dependent upon the derangement of the nervous apparatus connected Avith the organs of hearing appear to be caused by the condition of the brain generally, or of that part in intimate relation Avith the acoustic nerve, it has seemed desira- ble to divide the nervous diseases of the ear into tAvo classes; to the first of Avhich belong those cases where the special nervous apparatus of the organ is alone affected ; to the second, those where the brain, conjointly Avith the ear, seems to be injured. The first class may be divided into diseases arising from : 1, concussion ; 2, the application of cold; 3, various poisons, as that of typhus, scarlet, or rheumatic fevers, of measles and mumps, of gout, of an accumulation of bile in the blood, and of quinine in large doses. Anel the second into diseases arising from: 1, excess of mental excitement; 2, physical debility. In the first class of cases there is not nnfrequently ringing and sino-ing in the ears, with other morbid sounds, anel sometimes a feeling of giddiness and unsteadiness extremely unpleasant. From its commencement there is frequently a continuous in- crease in the deafness; but in other cases it remains the same, and in still others there is gradual improvement. It is gener- ally conceded that in very many cases there is congestion of the nervous apparatus of the internal ear, though if it continues for a considerable time it will very likely terminate in structural change. The treatment will vary in these cases, in some the remedies being selected from those which influence the nervous system di- rectly, in others from those Avhich influence the blood, and in 448 diseases of children. still others from those which influence waste anel excretion. Of the first class Ave find marked benefit from Rhus, Bryo lia, Sticta, Belladonna, Apocynum, Bromide of Potash, Bromide of Ammo- nium, etc. Of the second, FoAvler's Solution of Arsenic, Cod liver Oil, Donovan's Solution, Phytolacca, Alnus. The third class Avill embrace the alkaline diuretics, and remedies that increase secretion from skin and bowels. Persistent counter-irritation over the mastoid portion of the temporal bone, with cantharieles, or the irritating plaster, is one of the most important parts of the treatment. These measures, folloAved up for months, Avill occasionally produce the most marked benefit, the hearing being sometimes completely re- stored; but in other cases no benefit results. In the second class of cases Ave Avill have more or less evidence of cerebral disturbance, though frequently the symptoms are im- perfectly marked. No treatment can be laid down for these cases, as the symptoms are so variable and changing. They should be treated on general principles, and Ave will sometimes be agreeably surprised at a favorable termination in cases Avhich had seemed hopeless; and not nnfrequently Ave will fail when Ave seemed to have the best chance of success. CHAPTER XII. DISEASES OF THE SKIN. Difficult of classification in all cases, Ave find diseases of the skin doubly so in the child. True, some cases are so avcH de- fined that the merest tyro will assign them their proper place ; but others are obscure from the first, and more become so as they progress. Probably, the simplest classification is that adopted by Cazenave, into eight orders. The following brief description of each will enable the reader to classify many cases : Exanthemata.—This term is applied to patches of a reddish color, varying in intensity, size and form, disappearing under pressure of the finger, and terminating in delitescence, resolu- tion or desquamation. DISEASES OF THE SKIN. 449 Vesiadae.—A vesicle is a slight elevation of the epidermis, containing a serous anel transparent fluiel, which, however, is oc- casionally opaque or sero-purulent. The vesicle may terminate in absorption of the fluiel, slight desquamation, excoriation, or the formation of small, thin incrustations. Bulhv.— Generally speaking bullae differ from vesiculae merely in size; they are small superficial tumors caused by effusion of serum underneath the epidermis. Pustuloe.—This term should be strictly confined to circum- scribed collections of pus on the surface of the inflamed mucous hryer. The contents of the pustules in drying produce scales, and they may be folloAved by chronic induration, or by red in- flamed surfaces, or sometimes by slight excoriation. Papuloe.—These are small elevations, which are solid, resist- ing, and never contain any trace of fluid ; they may likeAvise give rise to ulceration, but generally terminate in resolution ami furfuraceous desquamations. Squamae.—The term squamae is applied to the scales of thick- ened, dry, whitish, friable, and degenerated epidermis, which cover minute papular elevations of the skin ; they are easily de- tached, and may be reproduced for an indefinite length of time by successive desquamations. Tuberculce.—These are small hard tumors more or less promi- nent, circumscribed in form, and persistent; they may become ulcerated at the summit, or suppurate partially. In this defini- tion Ave consider tubercles as elementary lesions, and not those which appear after abscesses. Maculae—Are permanent changes in color, in certain points of the skin, or of the Avhole cutaneous envelope, but unattended with any general derangement of the health. ORDER I.-EXANTHEMATA. The general characteristics of this order are Avell marked at first, though in the progress of the disease they may so change that they will approximate some of the others. They always commence with redness of the skin, which is effaced for the moment by pressure, returning as soon as this is removed. Some of them, as erysipelas, rubeola and scarlatina, are attended 29 450 DISEASES OF CHILDREN. Avith marked constitutional disturbance, and in the last tAvo, as Ave have already seen, the cutaneous disease is associated with disease of the throat and respiratory apparatus, and in all three of the diseases named there is in some cases marked lesion of the blood. ERYTHEMA. Erythema is one of the mildest of the exanthemata, and usu- ally is not accompanied Avith febrile action, though in the severer cases there is arrest of secretion and some constitutional disturbance. It may be produced from mechanical irritation of the skin, but the most frequent causes are cold and arrest of cutaneous secretion, or gastric and intestiual derangements. Symptoms.—The disease appears in the form of patches of variable size, of a light, superficial red color, readily effaced by pressure, and most frequently on the face, chest and limbs. In some cases they spread so as to cover a consielerable portion of the body, but this is not frequent. One form, termed erythema nodosum, is preceded by slight constitutional disturbance, anel conies out in oval, red patches, from half an inch to an inch in diameter, most generally on the loAver extremities. AVhen more fully developed they are slightly elevated above the adjacent skin, and in a feAV days form small, red, painful tumors, Avhich seem inclined to suppurate, and in severer cases give a suspicious sense of fluctuation, but at last disappear Avithout any change of structure. The first form may last but a few hours, or in rare cases it may continue tAvo or three weeks ; the second usu- sually continues for from three to six days. Before the eruption makes its appearance the child is some- times quite sick, and the febrile action is marked, and if there is a sudden retrocession, Ave sometimes find the child restless and uneasy, with nausea, pain in the head, and frequent pulse. Treatment.—Usually Ave put the patient upon the use of small doses of Aconite, with Belladonna if the eruption is not out freely; Rhus if there is frontal pain, startings in sleep, and red papillae on tip of tongue; Apis if there is itching of the sur- face ; Gelseminum if the face is flushed and the patient restless; Apocynum if the eyelids are swollen. The surface should be bathed with a Aveek solution of carbon- ate of potash, (alkaline bath,) and in some cases Ave Avould use the ROSEOLA. 451 warm foot-bath. In the second form of the disease, I have usu- ally prescribed a gentle laxative, Avith a solution of acetate of potash, and very small doses of Aconite. The use of the alkaline bath gives great relief, and it may sometimes be repeated several times a day. In some rare cases there seems to be a tendency to excoriation, and in such cases I Avould advise a lotion of—ly Glycerine, §j., Chlorate of Potash gr. xx., rose Avater 5ij.; mix. Or the part may be dusted Avith poAvdered subnitrate of bismuth. ROSEOLA. Roseola, or rose rash, is a mild exanthematous eruption, con- tinuing from one to six or seven days, and attended by more or less febrile action. The causes are obscure, though arrest of 7 O secretion and gastro-intestinal irritation, are the most frequent. It sometimes occurs as an epidemic, especially in warm seasons, and sporadically, from over-heating the body, severe exercise, etc. Four varieties have been distinguished : R. infantilis, R, cestiva, R. autumnalis, and R. annulata. Symptoms.—Roseola infantilis, as its name indicates, is usually met with in young children, and arises form gastro-intestinal irritation, or from dentition. It comes out in the form of deep rosy-red patches about one-fourth of an inch in diameter, and circular in form. AVhen severe, they are very much croAA'ded together so as to give a general red appearance to the surface, but yet each one is Avell defined. They may continue for several days, or vanish and reappear for several days. Usually the fever is but slight, but the child sIioavs symptoms of irritation, being cross and fretful. Roseola cestiva is usually ushered in by marked febrile action, and in children delirium or convulsions sometimes supervene. The eruption usually appears about the third or fourth day on the face and neck, and in a feAV hours involves the greater part of the body. "The spots are of a deep red color, more irregular in shape than those of measles, and their original color soon passes into a light rosy hue. There is also present a consider- able de°ree of itching and pain, and often difficulty in SAvalloAv- ' ino\" The disease runs a very variable course, but the erup- tion usually disappears in three or four days Avithout desqua- mation. A bastard measles, which is contagious, resembles this 452 DISEASES OF CHILDREN. form of roseola. It is knoAvn as ratheln, or German measles, and as it occurs where children have had true measles, many have supposed that persons could have the disease tAvice. Roseola annulata comes out in the form of rose-red rings, in the center of Avhich the skin retains its natural color ; it is said to be principally observeel on the abdomen and buttocks. It is not usually accompanied with much fever, but is occasionally very persistent, and is usually associated with gastro intestinal irritation. Diagnosis.—Roseola may be distinguished from measles by the spots being larger, circular, circumscribed, and of a deep rose color, Avhile the patches of measles are small, irregular, and of a common red color. The eruption of scarlet fever consists of a great number of small red points of a scarlet or raspberry color, and grouped together so as to form irregular patches. Treatment.—The patient has the proper sedative in small doses, to Avhich may be adeleel such remedy influencing the skin as may be indicated. If there is dullness or inclination to sleep, Belladonna is given until the eruption comes freely to the sur- face, and the nervous system is relieved. If the pulse is sharp, the toague sIioavs the red papillae, and there is frontal pain, or burning of the surface, Rhus is the remedy. If the itching is severe, adel Apis to the solution of Aconite. Phytolacca is given if there is soreness of the mouth and throat; the carbonate of soda, if there is a pallid tongue ; sulphite of soda, if the tongue is broad, pallid and dirty; anel sulphurous acid, if the tongue is red and dirty. AVhen there are frequent recurrences of roseola, we may sus- pect some Avrong of the gastro-intestinal apparatus, or a failure in Avaste and excretion. Sulphite of soda and sulphurous acid are frequently indicated in these cases, and their administration effects a cure. Lime-water or minute doses of sulphite of lime, will frequently prevent a recurrence of the attacks. In some cases the patient Avill be benefited by Nux, in others by arsenic, anel in still others by cod-liver oil. Occasionally tincture of mu- riate of iron in small doses exerts a good influence, the disease resembling a mild form of erysipelas. In other cases Pulsatilla Avill prove a good remedy, and in still others a second trituration of Podophyllin may be given. diseases of the skin. 453 URTICARIA. Urticaria, or nettle-rash, occurs most frequently in childhood, though we occasionally see cases of it in the adult. The most common cause is doubtless gastro-intestinal irritation, though the milder forms may be caused by sudden changes of tempera- ture, or excessive mental emotion. Sometimes it is an acute affection, but more frequently it assumes a chronic form, and may last for months or years, reappearing on the slightest imprudence of eliet or change of habits. The reader will knoAV urticaria by its more common name, hives, and if he has had much experience Avith it, he will recall many unpleasant cases. It not only varies in intensity and du- ration, but also in the appearance of the eruption, in size, form, and color; but in all there is the common symptoms, intense persistent itching, and sometimes burning of the skin. Symptoms.—Though divided into several varieties, it will suit our purpose to consieler it as febrile and non-febrile. In the first case the eruption is preceded for a day or tAvo by slight febrile symptoms, irritation of the stomach, and pain in the epigastrium. The eruption then comes out in the form of reel or pale-reel blotches, irregular in shape, elevated above the aeljaeent skin, hard around their edges, anel surrounded by a bright red or scarlet border. An intolerable pruritus and burning accompany the eruption, aggravated by-warmth, and usually by scratch- ing or rubbing the part, and is sometimes so seA'ere as to prevent the patient's sleeping. The eruption is not constant, but goes aAvay and re-appears sometimes every feAV hours. The disease usually continues fen* seven or eight days, with some constitu- tional disturbance during the entire period, anel at last disap- pears, leaving but slight itching; in severe cases there may be some desquamation. In some cases the eruption fails to come out, and the patient suffers from extreme nausea, nervous irritation (sometimes going on to convulsions), anel occasionally marked febrile reaction. The swollen face and slightly mottled skin, will frequently sug- gest hives, and we relieve the patient by bringing the eruption to the surface. When there is a retrocession of the eruption, the patient is sometimes very sick, so that between the intense itch in*' and burning Avhen the hives are out, and the nausea and 454 DISEASES OF CHILDREN. great prostration or febrile action Avhen they go in, the patient passes a very unpleasant Aveek. In some cases marked croupal symptoms are observed, and this becomes an important feature. The non-febrile form is usually chronic, and has been divided into tAvo varieties, U. evanida and U. tuberosa. In the first, the eruption appears at irregular intervals sometimes for months or years, is not attended by febrile action, and has not the red border just noticed; the spots look more like those produced by Avhipping, and are only accompanied by itching. The last form is very rare, and instead of the slightly elevated blotches, there are broad, hard, deep-seated and painful tubero- sities which impede motion. It passes off and reappears like the preceding variety, but almost always leaves the patient fatigued and depressed. Diagnosis.—There is but one disease (lichen urticatus) with Avhich this can be mistaken, and from that it may be distin- guished by the large irregular blotches, while in litchen, the papulae are rounder, less prominent, smaller, harder, and of a deeper color. Urticaria may be complicated, hoAvever, Avith erythema, roseola, impetigo and litchen. Treatment.—In the majority of cases the prescription will be—Py Aconite gtt. iij. to gtt. v., Tincture Belladonna gtt. v. ; a teaspoonful every hour until the eruption comes out freely anel the patient is relieA'ed. If now Ave substitute—Py Tincture Apis gtt. v., Tincture Phytolacca gtt. x., water 5iv., a teaspoonful eA-ery tAvo hours to relieve the itching, our patient will make a rapid recovery. AVhen there is severe burning as Avell as itching the patient Avill have Rhus with the Aconite. In some of these cases the irritation of the nervous centers Avould call for Rhus if there was not the prominent symptom, "burning with itching." In rare cases, the evidences of accumulations in the stomach__ heavily coated tongue and fullness in the epigostrium—will de- mand an emetic. Usually the nasty tongue and breath will be met with sulphurous acid, or sulphite of soda. If there is marked oppression of the respiratory apparatus, with cough, and increased secretion of mucus, we may usee Lobelia, either with Veratrum, in the usual way, or as named heretofore, fy Tincture Lobelia 5j., Comp. Tincture Lavender ERYSIPELAS. 455 onj., simple syrup 5iss., Croupal symptoms are best met by an application of stillingia liniment over the larynx, and sometimes its internal administration in half drop or drop doses. If con- vulsions are threatened the patient should have bromide of ammonium. AArhen the skin is feeble, anel the eruption does not appear, the patient may be rapidly sponged with hot Avater, befe)re a fire, being careful to prevent chill. A hot foot bath (a full half hour and plenty of water hot) will sometimes give great relief. AVhen the eruption is out, and the patient complains of excessive itch- ing, the old-fashioned alkaline bath may be employed, or a salt water bath will sometimes give relief. ERYSIPELAS. Erysipelas Avould have been more properly classed with febrile diseases, as in many respects it resembles them. The constitu- tional affection is the primary disease, and of which the local in- flammation i.s but the outgrowth. It is not so frequently met with in children as in the adult, but occasionally is quite a serious affection. Thus we will see it during the first Aveek of life in erysipelatous inflammation about the umbilicus; at a later period affecting the genitalia and nates; and from two years upAvard attacking the extremities. It is a singular fact that children rarely have erysipelas of the face, which is the most common seat of the disease in the adult. Causes.—Erysipelas undoubtedly belongs to the class of zymotic diseases, in Avhich there is a blood-poison. AVhat this peculiar poison is, Ave do not knoAV, or how it is generated, farther than that it seems to be produced in certain depressed conditions of the system, Avhere there is rapid Avaste of tissue and imperfect excretion. When once generated, it has the poAver of propagating itself, and at times will become eminently con- tagious. Pathology —As above remarked, the disease is undoubtedly produced bv a blood poison, and the first lesion is of the fluiels, manifested by the usual symptoms of fever. Following this, avg have an inflammation of the skin, and occasionally of the deeper tissues. The inflammation does not at first seem to differ from that produced by other causes, further than that the circulation 456 DISEASES OF CHILDREN. is more impaired. But as it advances the tissues seem to lose vitality, and the exudation is of a depraved serum rather than coagulable lymph. Symptoms.—The symptoms vary in different cases, not only in intensity, but in their order. Usually, the chilel seems de- pressed for a day or tAvo, the appetite being impaired, the breath bad, and the sleep broken. Follenving this there is febrile action, frequently coming up sloAvly, but sometimes rising quickly and running an active course. AVith the appearanee of the fever the cutaneous disease shoAVS itself, usually in the form of a red spot, Avhere the skin is evi- dently SAVollen, hot and painful. As the elisease progresses, Ave finel the redness extending, Avith the same induration of the skin, and other evidences of inflammation. Occasionally in the course of two or three days the epidermis is loosened and distended with a yelloAvish serum, forming bullae of larger or smaller size, and these rupturing pour out their secretion, and sometimes become covered with thin in- crustations. The redness usually fades, and the inflammation commences to disappear by the fifth or sixth day, leaving the epidermis wrinkled and yelloAvish, and at last it desquamates over the entire surface. The fever is in some degree dependent upon the local lesion. AVhen this is acute it runs a very active course, and gradually subsides as the inflammation passes off. In other cases the feA'er is of an asthenic type, and sometimes presents marked typhoid symptoms. We observe another form of the disease in children of from six to twelve years. They complain of soreness of the legs and feet and lameness, and when examined the parts are slightly SAvollen, the skin smooth and glistening, and presenting a peculiar mottled red and purplish discoloration. The chihl's health has not been good for some days; its appetite is im- paired, itsboAvels irregular, breath bad, and it is evidently losing flesh. Diagnosis.—The peculiar redness of the skin, with swelling anel the burning heat that attends it, are characteristic. Associa- ted Avith this is the marked constitutional disturbance, rendering the diagnosis certain. ERYSIPELAS. 457 Prognosis.—Usually Ave will have but little difficulty in con- trolling the local and general disease, and remedies will gi\*e much satisfaction. Some eases will be quite intractable, but upon the whole the mortality will be but small. Treatment.—The treatment of erysipelas illustrates the truth of specific medication, both as regards the action of the small dose, and the advantage of following special indications fin- the selection of the remedy. If the reader will consult the article "Anti-erysipelatous Remedies," in the first part of this work, he will be able to see this better. The remedies in common use are Veratrum, Rhus, Tinct. Muriate of Iron anel Sulphite of Soda. Veratrum is inelicated by a full pulse, and the ordinary red- ness of inflammation, all the inflammatory symptoms being marked. It is given internally in the proportion of—R Tinct. Veratrum gtt. v., Avater 5iv., a teaspoonful every hour, and ap- plied locally of full strength, to one part to ten of water, or water and glycerine. Rhus is indicated by the brighter redness, burning pain, vesi- cation, sharp pulse, and irritation of the nerve centers. AVre prescribe it as folloAvs—ly, Tinct. Rhus gtt. iij. to gtt. v., Tinct. Aconite gtt. iij., Avater Siv., a teaspoonful every hour. AVhen indicated its action is very prompt and decided. Tincture of muriate of iron is given in small doses, Avhere the mucous membranes are red, either dusky or livid. The remedy is best given with glycerine as heretofore named. This is also the remedy for the last form named, and its continuance for a feAV days Avill entirely remove the unpleasant symptoms, without local applications. Where the tongue is pallid, broad, and covered with a pasty Avhite coat, sometimes pitting where it conies in contact Avith the teeth, sulphite of soda is the remedy. To a child two years old it may be administered in doses of three to five grains every tAvo hours. In young children the best local application is soft cloths spread with fresh lard. In other cases Ave will find an excellent remedy in one part of the tincture of muriate of iron to five parts of glycerine AVhen the erysipelatous inflammation is deep seated, and likely to progress to sloughing, a solution of Permanganate of Potash, oj., to water, Oj., used as a wet dress- ing will be found an admirable remedy. 458 DISEASES OF CHILDREN. ORDER II —VESICULiE. The distinguishing characteristic of this order is, the forma- tion of small vesicles by an elevation of the epidermis, Avhich are filled Avith a serous fluid. This fluid, at first transparent, in severe cases becomes yelloAvish and opaque, and is finally either absorbed, or dries anel forms scales or incrustations. The vesicle is ahvays round, and may or may not stand upon an inflamed base. One variety of tins order, varicella, has already been de- scribed with the eruptive fevers, MILARIA. Milaria, or sudamina, most generally appears as an attendant upon other diseases, more especially typhoid, aiid the advanced stages of other fevers and inflammations. There are exceptional cases in "Avhich it assumes an idiopathic form, as for example, when it appears in healthy subjects after violent exercise in warm Aveather; in these instances it is generally accompanied with copious perspiration. The eruption is then attended Avith a dis- agreeable sensation of heat and itching. The number of \'esi- cles is sometimes very considerable, but they are ephemeral, and disappear in the course of tAventy-four hours."—(Cazenave.) The miliary vesicle is small, not larger than a pin's head, and the contents being clear and transparent, it can not be seen Avell unless Ave look across the surface. They are usually grouped together in patches, upon the thorax and neck, and in rare cases become confluent, forming bullae. They demand no treatment, being simply symptomatic of other diseases. ECZEMA. Eczema, humid tetter, or running scall, is characterized by an eruption of small vesicles grouped and crowded together, and forming more or less Avell defined patches. It may be divided into the acute and chronic form, and these have to be still fur- ther divided into several varieties. The causes of eczema are very obscure, and it is non-contagious, except in rare cases where the disease affects the genital organs. Symptoms.—Eczema infantilis is the milk-scall that is some- times found so troublesome during the first year, and occasionally ECZEMA. 459 continuing after this. It makes its appearance in the form of transparent vesicles about the ears, sometimes upon the face. These increase in number, gradually extending from part to part, until a large surface is diseased. The vesicle continues but a day or two, then rupturing, a crust is formed, beneath Avhich pus in found, and the crust is reneAvcd as often as detached. Thus running together, large surfaces are covered with single crusts, from Avhich there is an offensive discharge. In many cases the disease manifests but little tendency to recovery, sometimes continuing for months. Eczema simplex commences with a sensation of itching, which is soon followed by the appearance of numerous small trans- parent vesicles, flattened, and set close together; after a time the fluid they contain becomes opaque, and they finally rupture, forming a small thin scab which is soon detached. They appear more frequently upon the fe>re arm, and where the skin is thin anel delicate, and frequently betAveen the fingers, somewhat re- sembling the itch. Eczema rubrum is accompanied with considerable heat and tension of the skin, and at first the vesicles may be observed as small solid points, but they soon become true vesicles, which attain the size'of a pin's head, and finally disappear about the sixth or eighth day. In some cases the vesicles coalesce and rupture, a disagreeable excoriation producing repeated incrustations being left.° In eczema impetignodes the inflammation of the skin is very marked and it is swollen, the vesicles are larger, and the con- tained fluid loses its transparency and becomes purulent, and finally they rupture, formiug a scab, which is thrown off and re- formed sometimes for tAvo or three weeks. Acute eczema of the two last forms is usually attended with well marked febrile action, which continues for two or three days, and sometimes for a longer period. The eruption is always accompanied by itching, Avhich is sometimes very severe and troublesome. Chronic eczema most generally results from an acute attack, anel may continue for months, or even years. In these cases the skin becomes deeply inflamed and excoriated, and fissures form about the joints; a continuous ichorous discharge is kept up, which increases the irritation, and forms thin crusts, or coming in contact with the clothing agglutinates it to the part, and when removed there is much pain and smarting, and sometimes a con- 460 DISEASES OF CHILDREN. siderable floAV of blood. AVhen the crusts are detached, the sur- face is found reddened, soft, and SAvolleu. In other cases there is less exudation, the skin being dry, inflamed, and fissured, anel covered by slight crusts. "Chronic eczema is invariably attended with intense itching, more distressing than the severest pain. The patient in vain struggles against it, but he can not, hoAvever, resist the urgent desire to scratch himself, ami thus increases his suffering. After a certain period the itching begins to subside, the serous exudation gradually ceases, the scaly inorustatiems dry up, and the skin is less inflamed. Finally, the disease becomes reduced to a small, dry, red surface, which is covered with ex- tremely thin, laminated crusts. The surrounding skin is smooth, tense, and firm, and only sloAvly resumes its natural state." (Cazenave) Diagnosis.—It may be distinguished from itch by the flatness of the vesicles, and their being grouped together, Avhiie in itch they are pointed and isolated. The diagnosis of chronic eczema from lichen is sometimes difficult, but usually the presence of papulae near the red inflamed surface is sufficient. Treatment.—In acute eczema, if there is some febrile action, Ave prescribe Aconite with Rhus; or if there is no frequency of pulse or increase of temperature, Rhus with Phytolacca. Rhus exerts a specific influence upon the skin, and if there is no indi- cation for other remedies, it will serve a good purpose in all these cases. In some it can be given in full doses, but in many it must be used in small doses, for in the usual quantity it increases the eruption. Phytolacca is especially a good remedy when there is fullness of the lymphatic glands. If I Avere called upon to select a specific remedy for eczema, I should take sulphite of soda, especially in the chronic form. In many cases the indications for it will be found at first, in the moderately full and pallid tongue, dirty. In other cases sulphu- rous acid Avill be the remedy, in doses of gtt. x. to 5ss. three or four times a day. In chronic eczema with a pallid and atonic skin, Fowler's So- lution gtt. x., Tinct. Phytolacca gtt. x., Avater 5iv., a teaspoonful four times a day, Avill prove beneficial. In rare cases Donovan's Solution may be substituted for FoAvler's. Cod-lh-er oil, the compound syrup of the hypophosphites, lime-water, hypophosphite of lime, and occasionally some of the HERPES. 461 vegetable; alteratives, especially the Alnus, Rumex, and Scroph- ularia, will come in place Sulphur in the old-fashioned dose may sometimes be used, if the disease is very persistent. In milk-scall I have obtained marked advantage from the use of an ointment from the inner bark of the common elder (Sam- bucus). Occasionally a glycerole of starch ansAvers the purpose Avell, or a small portion of oxide of zinc may be added to it. In very severe cases of chronic eczema, I employ broAvn citrine ointment one part with two parts of simple cerate. It is to be employed carefully, and not on too large a surface at once. In other cases an infusion of Alnus, Rumex and Quercus Rubra, is an excellent local application. In some cases a general bath, rendered emollient by the addi- tion of mucilage or gelatin, Avill be beneficial; it should be about ninety degrees Fahrenheit, and continued for an hour or longer. In place of this Ave may use the vapor bath, repeating it two or three times Aveekly. HERPES. Herpes is most generally an acute disease, and is characterized by an eruption of vesicles grouped together on an inflamed base. The causes are unknown. Five varieties are distinguished : H. phlyctenoides, H. labialis, H. praeputialis, H. zoster, and H. circinatus. Symptoms.—Herpes phlyctenoides is usually attended by slight indisposition, loss of appetite, and constipation. The patient feels a smarting, burning sensation of some part, and upon examination finds a number of slightly red spots, upon Avhich in a short time is developed six or eight firm and prominent vesi- cles from the size of a millet seed to that of a small pea. At first they are transparent, but in the course of a day become opaque and milky ; there is frequently a sensation of itching, and sometimes the part feels quite painful. They commence to decline about the fourth or fifth day, drying up and leaving larger or smaller incrustations, and by the eighth or tenth day they have entirely disappeared, nothing but redness of the sur- face remaining. Herpes labialis is usually preceded by slight indisposition and fever and hence the vesicles are often termed fever blisters. It usually comes out at the junction of the skin and mucous mem- 462 DISEASES of children. brane, but may appear in the mouth, or as far back as the pharynx. It is usually preceded for a feAV hours by redness, and sometimes the part is SAvolleu and painful. The vesicles are of various sizes, the largest about the size of a small pea; at first they are transparent, but in two or three days become opaque and yelloAv, and in tAA'o or three days more desiccate, forming brownish crusts. Herpes proeputialis appears on the external surface of the prepuce, small inflamed spots being first noticed, Avhich, in the course of a few hours, are covered with groups of small globose vesicles. It runs a similar course to that just noticed, but in some cases continues to reappear for years, causing great annoy- ance to the patient. Herpes zoster, or shingles, is usually the severest form of the disease, being attended in many cases Avith marked febrile action. It usually makes its appearance on the trunk in irregular patches of a red-color, Avhich are soon covered Avith vesicles; new patches coming up, the disease may pass entirely round the body, though Cazenave states that it never appears but upon one side at a time. The vesicles resemble those already described, but are sometimes larger; they usually disappear in four or five days, leaving at some points thin, broAvn incrustations, Avhich are soon detached. The disease usually lasts for ten or fourteen days, and sometimes longer. Herpes circinatus, or ringworm, appears most frequently upon the face, neck and arms, though it may come out on any portion of the body. It comes out at first as a red spot about the size of a dime on which shortly appear numerous small vesicles ar- ranged in rings, hence the common name of ringAvorm ; it is not attended with constitutional disturbance, and generally disap- pears in ten or tAvelve days. Diagnosis.—The diagnosis of herpes is generally easy, the vesicles being rdund, prominent, anel grouped together on one inflamed or red base; the symptoms of the different forms are usually sufficiently marked for their easy distinction, as above described. It is generally thought that but little if any treatment is re- quired in herpes, but many times this is a mistake, for the erup- tion is but a symption of a deeper disease, and if not looked after it may leave permanent impairment of the health. In the first DISEASES OF THE SKIN. 463 form of the disease, the patient may have the usual doses of Aconite with Rhus, or Phytolacca, until the eruption has ceased and the crusts are thrown off. Sometimes a day's treatment will thus remove the disease when otherwise it might have lasted for ten days. The same treatment may be adopted for herpes labialis, or Aconite with Phytolacca. But occasionally in both these forms there will be indications for sulphurous acid or sulphite of soda, and the general health will be much improved by their use. Herpes labialis is sometimes an unpleasant symptom. If per- sistent and associated Avith some pain in the chest, and slight cough, it indicates disturbance of all the vegetative functions, and eventually tuberculosis. Treatment cannot be commenced too early in such cases, and the patient should be carefully Avatched for some time. Herpes praeputialis is frequently cured Avith soap and water, a gooel castile soap, or Colgate's glycerine soap ; sometimes Ave order a lotion of ben-ax and rose Avater, salicylic acid with borax, or in some cases the application of the citrine ointment. Shingles is treated Avith the special sedatives and such addi- tional remedies as may be indicated. If there is nausea and prostration from non appearance or retrocession of the eruption Ave add Belladonna; if there is severe burning of the surface with nervous disturbance it is Rhus; with intense puritus Apis; Avith pallid tongue and soreness of the mouth and throat it will be Phytolacca; when the tongue is pallid and-dirty, sulphite of soda is given; when it is red and dirty sulphurous acid. Herpes circinatus is usually cured by the local application of a saturated solution of iodide of ammonium, or sulphurous acid. In some very persistent cases Ave will find internal remedies needed, and sulphurous acid, sulphite of soda, minute doses of arsenic, and cod liver oil may be suggested, as indi- cated. SCABIES. Scabies, or itch, though a vesicular disease, is produced by an animal parasite—the acarus scabiei—and hence, as this insect possesses a very tenacious vitality, the disease is rendered con- tagious by its transmission from one to another. The acarus is usually found a short distance from the vesicle, in a small fur- row leading from it. AVith good sight or a magnifying glass, it 464 DISEASES OF CHILDREN. can be seen as a small, round, grayish boely, sometimes moving, sometimes at rest. Under the microscope, its boely is seen te> lie oval, the back convex, anel marked witli curved lines, its heael covered with fine hairs, and eight legs passing fire)in its abdomen. The insect passes from one part to another, by burroAving under the epidermis, but is only conveyed to distant parts by the fingers, after scratching, and by the clothing. Symptoms.—Scabies almost always makes its first appearance betAveen the fingers and front part of the wrist, in the form of small pointed vesicles, containing a clear, limpid fluid, anel a a very fine line leading from it, and marking the situation of the acarus. An intense but pleasurable sensation of itching attends their appearance, and the patient can not resist the incli- nation to scratch'or rub the part, though this sometimes gives rise to a sensation of smarting if too severe As the disease progresses, the irritation of the skin by the nails usually pro- duces suppuration in the vesicles, the result being the formation of larger or smaller scabs, anel some inflammation and stiffness of the skin. In severe cases Ave occasionally see in the inter- space betAveen the fingers a large festering surface covereel with thick scabs, and the hanels so stiff anel painful that they can hardly be used. Sometimes the itch is confined to the hands, but in others it is conveyed to the flexures of the joints, to the perineum, around the anus, and in fact wherever the skin is thin and delicate. In all these situations Ave may have the suppu- rative action above named, so that occasionally instead of a mild vesicular disease, the patient Avill be covered with foul, painful, ulcerating sores. Itch never terminates spontaneously, but may last for years. In some cases it never passes the vesicular form first named, but in a majority, especially where cleanliness is neglected, it goes on to the formation of hard scales, and induration of the skin. Diagnosis.—The diagnosis of itch is generally not difficult, as the vesicles are pointed and solitary, while in eczema they are flattened, and in prurigo the eruption is first papular, as it is also in litchen, and in neither case does it appear betAveen the fingers, the frequent seat of scabies. The sulcus passing from the visicle in itch is a good diagnostic feature, though not usu- ally very well marked. In the severer stages of the disease, SCABIES. 465 there would be difficulty in the diagnosis were it not for the constant reappearance of the disease in its original form. Treatment.—The object of treatment is to destroy the itch insect, and whatever av'iII accomplish this with the greatest cer- tainty, and in the least time, Avill prove the best remedy. Sul- phur has formed the basis of most applications, and is I believe the best remedy. AVe may use it in the form of ointment mixed with lard, or Avith an alkali, as—R Sulphur Sub. §ij., Subcar- bonate of Potash 5j., Lard Sviij ; mix. Or, Py Prepared Chalk %\\., Sulphur, Tar, aa. 5yj., Soft Soap, Lard, aa. 5xvj.; mix. These ointments should be thoroughly applied to the parts affected. It is hardly sufficient to say, cleansed with soap and water, for it requires a thorough saturation of the affected part Avith soap, and then its removal Avith soft Avarm water'(soft soap is best). The parts should be thoroughly dried before the oint- ment is applied, and it may be toasted in before a fire. If iioav the patient's clothing is entirely changed, anel the old clothes boiled, Ave may expect an immediate cure; if not the process should be repeated. I have used a combination of—Py Sulphuret of Potassium, §ss., Oils of Rosemary and Lavender, aa. oj-, Lard 5a-j., mix, and apply as before. Cazenave states that after repeated trials they determined that the two folloAving formulae yielded the most satisfactory results—If Essence of Peppermint, Rosemary, Lavender and Lemon, aa. gtt. iv. to gtt. vj., Alcohol, ojss., weak infusion of Thyme, Ovj.; it Avas freely used, and the cure resulted in eight days. ly Iodide of Sulphur, Iodide of Potas- sium, aa. 5jss., water Oij; the mean duration being six days. They say, whatever the lotion employed, it is necessary not only to wet the affected parts, but to prolong its application, so as to produce that kind of maceration which is required to destroy the insect. A solution of sulphuret of lime, Sij. to the pint of Avater is very efficient, the cure being effected sometimes with three or four applications. In the milder forms of the diseases no internal treatment is necessary, but the patient should be guarded against cold, damp- ness, and sudden changes of temperature, and change his entire under-clothing every day. In the more persistent cases, we may give equal parts of sulphur and cream of tartar, to the ex- tent of keeping the bowels open, and in some cases where the 30 466 DISEASES OF CHILDREN. patient is cachectic, the bitter tonics and iron. I have cured the itch Avith a local application of the Phytolacca and Podophyllum, but I prefer the remedies first named. ORDER III.— BULLAE. This order, it will be recollected, is characterized by the form- ation of large blebs, or blisters, from the size of a pea to a hen's egg, sometimes with and sometimes Avithout redness of the skin. Properly speaking, there is but one variety, pemphigus, but some authors class rupia under this order. Both affections are usually chronic, and may appear in succession, on any part of the body. A\re have no knowledge of their causes further than they are usually associated Avith a cachectic condition of the system. - PEMPHIGUS. Pemphigus is almost always associated Avith general debility, and imperfect performance of the various functions of digestion, assimilation and secretion, though the person may seem to enjoy tolerably good health. It makes its appearance in the form of blebs, or blisters, from the size of a split pea to an inch or more in diameter, containing a thin transparent serum. They fre- quently increase in size for tAvo or three days, the fluid becoming straw-colored Avhen they are ruptured, and a thin broAvnish crust forms. Sometimes the surface heals at once, but at others these crusts are reproduced for several days or'even Aveeks. 4 Diagnosis.—The diagnosis is always easy when they first ap- pear, as in no other skin disease do we see such a large elevation of the epidermis. When they have ruptured the diagnosis is more difficult, but it may usually be distinguished from other affections by the broAvn thin scab, and by the dark-red irregular spot Avhen it is removed. Treatment.—In the milder form of the disease, Tinct. Rhus gtt. v., Tinct. Phytolacca gtt. x., water Si v., in teaspoonful doses every tAvo or three hours, will be sufficient to effect a cure. In cases Avhere the face is full and purplish, Baptisia may replace the Rhus. If the tongue is pallid and dirty, give sulphite of soda, grs. ij. to grs. v. every tAvo hours; if red and dirty, sulphurous acid rupia. 467 will be the remedy. If the disease persists, we may prescribe ly Fowler's Solution gtt. x., Tinct. Phytolacca, gtt. x., water r>iv.; a teaspewnful every four hours. In some cases cod-liver oil will be of service; in others the hypophosphite of lime, com- pound syrup of the hypophosphites, or some preparation of malt after meals to aid digestion. If the bullae are large, and the surface painful when they rup- ture, it may be dressed with equal parts of lime-Avater and linseed oil, or powdered elm, flour or hydrastis may be sprinkled on it to absorb the discharges. RUPIA. This, like the preceding disease, is almost ahA'ays associated with a cachectic condition of the system, and enfeebled vitality, avid appears most frequently among the poor, destitute, and ill- fed, though occasionally when the patients have all the comforts and luxuries of life. Its only relation to the preceding disease, or to this order, is in its first appearance, and it soon loses this resemblance. It is ahvays a chronic affection, lasting from two or three Aveeks to many months. Three varieties are distin- guished : R. simplex, R. prominens, and R. escharotica. Symptoms.—Rupia simplex appears in the form of bullae, ;about the size of a dime, round and flattened, and without evi- dence of inflammation. The contained fluid is at first a limpid serum, but it soon becomes opaque and purulent, and finally concretes, forming thick flat crusts, of a broAvnish color. These fall off in a feAV days, leaving a superficial ulcer of the skin, which soon cicatrizes, but a livid-red color remains for some time afterward. Rupia prominens makes its appearance in a smilar manner, but the bullae are frequently larger, and the ulceration deeper, and the scales thicker. Usually the skin is reddened, and some- times there is a burning sensation and pain. The scab seems to groAV, in many cases, by continued additions at the base, and becomes one-fourth or even half an inch in thickness, and coni- cal, and resembles to some extent a snail's shell. AVhen the scab is removed, a new one frequently takes its place, and they may be thus reformed for months. In some cases the ulcer is healed with difficulty, the edges being livid and tumefied, the center pale, and bleeding on slight pressure. 468 DISEASES OF CHILDREN. Rupia escharotica occurs most frequently in children up to two years of age. It commences with the appearance of slightly prominent livid patches, upon Avhich irregular and flattened bullae are soon formed ; Avhen the bullae break, ulcerated surfaces are left which secrete a disagreeable unhealthy pus. ''The infant suffers from acute pain, and much fever and insomnolency. AVhen the disease assumes an intense form, death may ensue in one or tAvo Aveeks. When it does terminate favorably, the ulcer- ations are very long in healing." (Cazenave.) ^ Diagnosis.—Rupia is diagnosed with ease, in most cases, by the prominent, conical, brown scabs, those of pemphigus being flat. Ecthyma resembles it most in some cases, and it will be difficult to distinguish betAveen them in its later stages, but the hard and inflamed base, irregular scabs, and superficial excoria- tions, are usually sufficiently diagnostic. Treatment.—The treatment in this disease, as in the pre- ceding, should be strictly tonic, arrest of the skin disease depend- ing to a great extent upon the restoration of the general health. I have obtained the best results from the administration of FoAvler's Solution of Arsenic with Phytolacca as heretofore named. Cases Avill be found requiring Rhus, Apis, Cenwdalis and Alnus, and either of these may be associated or alternated with Arsenic. When the tongue is pallid and dirty, Sulphite of Soda may be given in the usual doses, and continued for some Aveeks. Occasionally Sulphurous Acid will be indicated. In rare cases Donovan's Solution of Arsenic will prove better than FoAvler's. If there is much derangement of the stomach, we frequently derive benefit from an emetic, and in many cases, excretion needs to be stimulated Avith small doses of the alkaline diuretics. Associated with these means, the patient should have a daily bath of salt and Avater, or in some cases of a decoction of Cornus or Hydrastis. The diet should be nutritious, and exercise should be taken in the open air. AVhen the local affection is very persistent, Ave may dress the ulcer Avith three parts of glycerine, and one of tincture of muri- ate of iron; or with the mild zinc ointment, black salve, or an ointment made of the inner bark of the elder. Sometimes a de- coction of equal parts of Cornus, Alnus and Rumex, ansA\*ers an ECTHYMA. 469 excellent purpose, or the tinctures of the same agents may be used. Salicylic Acid with Borax (oj. of each to water Oj.) is a good dressing; or Thymol grs. ij, to grs. iv., to Avater 5j., may be employed with good results. AVhen the ulcers are very per- sistent, they may be cauterized with a saturated solution of chloride of zinc, or a paste made Avith this and Hydrastis; and after the slough is cast off, the part usually heals kindly with any simple dressing. ORDER IV.-PUSTUL.E. This order is distinguished by the formation of small eleva- tions containing pus, and hence termed pustule They are almost invariably situated on an inflamed base, which usually precedes the eruption, though in some cases the inflammation comes on after the appearance of the eruption, and is more or less diffused. The eliseases included under this order are both acute and chronic, two of them, variola and vaccinia, heretofore described, being eminently contagious, and one, porrigo, being propagated by contact. The others seem to depend upon some uuknoAvn internal cause. ECTHYMA. Ecthyma may be divided into the two forms, acute and chronic, the first occurring most frequently in children ami young persons, the second in the adult, though sometimes in children. Symptoms.—In the acute form it is usually preceded by lassi- tude and indisposition, and its appearance is frequently marked with slight chills and febrile action. It makes its appearance in the shape of red, circumscribed, inflamed spots, which soon suppurate at their apices. In some cases the eruption is attended with pain, the inflammation being quite severe, but in others it is simply a sense of stiffness. Some of the pustules terminate by resolution, Avhile others are succeeded by a thick, adherent scab, which, in falling off, leaves a deep-red mark, and in some cases a cicatrix. It usually lasts for one or tAvo weeks. In chronic ecthyma there is a successive appearance of the eruption, sometimes for months, the general health being much depressed. It may present the same character as that just de- scribed, or it may become confluent in large suppurating sur- 470 DISEASES of children. faces. A variety termed ecthyma cachecticiim, occurs in old persons, and those avIio have broken their systems doAvn by in- temperance. "The skin is inflamed and more SAvolleu than in the common forms of the disease. It assumes a deepened color, and in about six or eight days the cuticle is raised over the pus- tules, is blackish and infiltrated with blood. It soon bursts and forms a thick, dark scab, raised at the center; the edges are hard, callous, and more or less inflamed. The scabs are very adherent and do not become detached for several Aveeks, some- times for months. If they fall accidentally, an unhealthy ulcer- ation ensues, and the scab is Avith difficulty removed. Some- times febrile symptoms precede or accompany the eruption, but they generally disappear with the disease."—(Cazenave.) Diagnosis.—Ecthyma is usually recognized Avith ease by the hard and inflamed base, suppuration commencing on the surface, and not deep as in furunculi, acne, and sycosis, Avhich are most frequently mistaken for it, but in these the base is hard, not in- flamed, and the pustules are small and sloAvly developed. Treatment.—In the acute form of the disease Ave give the special seelative, Aconite or Veratrum, using the warm bath with glycerine soap. In some cases Rhus will be indicated, in others Apis, and in still others Phytolacca. If the tongue is broad and pallid, sulphite of soda will be found an admirable remedy, and will sometimes effect a speedy cure. If the tongue is red, with brownish coat (Ioavii the center, sulphurous acid Avill be given. In the chronic form of the disease, the patient may have Foav- ler's Solution, with Phytolacca, or cod-liver oil ; or, if congenital syphilis is suspected, Donovan's Solution, or iodide of potassium is indicated. In some cases the old combination of aa. Alnus, Rumex, and Quercus, in infusion, may be given internally, and used as a local application. If the eruption is very perverse, a local application of brown citrine ointment one part, with cod oil or simple cerate tAvo or three parts, may be used. It needs to be used with care, but it is very certain in its action. In some cases a dry dressing is preferable, and the part is dusted with subnitrate of bismuth. DISEASES OF THE SKIN. 471 POERIGO. Porrigo, or tinea, is a disease of the scalp, and is generally known by the name of scald-head. It is undoubtedly contagi- ous, and is propagated from one to another by contact; hence the necessity for care in the use of articles of clothing, combs, baushes, toAvels, etc. Tavo varieties are distinguished : P. favosa, or tinea capitis, and P. scutulata, or tinea annularis. Porrigo favosa commences Avith an eruption of minute, round, yelloAv pustules, Avhich seem to be imbedded in the skin. At first they are distinct, and situated on a hard base, but as the disease progresses they become confluent, the entire scalp being inflamed or indurated. In a short time after their formation, the yellowish fluid begins to concrete, and Avhen they are distinct forms a scab Avith a marked depression in the center, but Avhen close together they form one large scab. If this is alloAved to remain, it becomes thick, whitish, and brittle; if removed, slight erosions are seen under it, and it is not re-formed, except by the appearance of a neAV crop of pustules. " This affection is never accompanied with febrile symptoms, but a troublesome and annoying itching is often present during its progress, which is aggravated by Avant of cleanliness. A number of lice are often seen under the scabs, causing the pa- tients to scratch themselves, and by this means increase the in- flammation. In these cases there is a strong, disagreeable odor, similar te> that of cat's urine, given off from the head. After the head is cleansed from the scabs the odor becomes sickening. The excoriations on the surface, which often reach to the hair- bulbs, and thus produce baldness, are not covered Avith the reg- ular cup-shaped favus pustules, but a reddish and fetid sanies oozes out, which concretes into irregular-shaped scabs. Fresh pustules, however, soon appear, which give rise to fresh favus scabs. Small subcutaneous abscesses may sometimes appear, accompanied with sympathetic engorgement of the lymphatic glands of the neck. It has been remarked that the growth of those persons Avho have been affected Avith porrigo is often ar- rested, anel the development of the mental as well as the physi- cal powers is slow and imperfect. The duration of the disease is verv variable and uncertain ; anel the hair, when reproduced, is rarely the same as the original either in color or consistence." (Cazenave.) 472 DISEASES OF CHILDREN. Porrigo scutulata commences with the appearance of red cir- cular patches, upon which small yelloAv pustules are soon devel- oped. Each pustule has a hair passing through it, and has the same cupped appearance as in the preceding variety ; and they appear more frequently upon the circumference of the spot than at its center. The scabs increase in thickness for some time, and , when removed a large furfuraceous patch Avith an uneven surface is left, from which the hair frequently falls off. It spreads by spontaneous development, or by inoculation of other parts by scratching; marked and sometimes intense itching attending the eruption. Like the preceding affection, its duration is variable, but if allowed to run its course it would probably continue for years, resulting in permanent baldness. Diagnosis.—The presence of the small, rounded, yelloAv pus- tule, depressed in its center, is the diagnostic feature of both forms. Porrigo scutulata is determined by the appearance of the eruption in circular patches, though when these are numer- ous, they are so crowded together as to cover the entire surface, and the distinction then betAveen this and porrigo favosa can not be made out. Treatment.—Cleanliness is of great importance in this affec- tion, and to secure it Ave would have the hair cut close, and the head frequently Avashed with castile soap and water. It may be necessary at first to soften the incrustations by continuous emollient applications, or in some cases with poultices, using soap and Avater freely in the meantime. Having thus exposed the scalp Ave would apply—R^ Oxalic Acid, grs. x. to grs. xx., Creosote gr. x., water Sij.; M., and folloAV it in half an hour with free inunction of mild zinc ointment. The ointment of iodide of sulphur is a very efficient remedy, and should when used be gently rubbed over the parts night and morning, the scalp being kept perfectly clean by the use of soap and Avater. A nicer application and a more effectual one will be found in broAvn citrine ointment one part, simple cerate tAvo parts. The head may be thoroughly cleansed Avith a solution of salicylij acid and borax (aa. 5j. to water Oj.,) and the ointment then carefully applied. As regards internal remedies, we will find it necessary to give the vegetable alteratives heretofore named, associated with some LICHEN. 473 preparation of potash, as the iodide, acetate, carbonate, etc. Sulphite of soda is an admirable remedy in some cases, and sul- phurous acid is occasionally indicated. Usually the bitter tonics and iron will be required to some extent, and occasionally cod- liver oil will prove beneficial. ORDER V.—PAPULiE. This order is characterized by small, firm, solid eleA'ations of the skin, ahvays attended with more or less itching, and never contain pus or serum, though occasionally from irritation these surfaces become ulcerate! and covered with incrustations. They are developed Avithout any appreciable cause, are rarely attended with febrile symptoms, and are not cemtagious. They are most generally chronic, but sometimes acute. Two diseases are in eluded under this order—lichen and prurigo. LICHEN. Lichen appears as small, hard elevations, but slightly red, or of the color of the skin, and attended with severe pruritus. We may distinguish three forms : L. simplex, L. agrius, L. urticatus. Litchen simplex comes out in the form of small and aggregated papulae, being attended with severe itching, and sometimes burn- ing. It most frequently appears on the face and arms, anel the neck and breast, though it may extend to all parts e)f the body. They remain stationary for three or four days ; when the redness gradually declines, there is slight furfuraceous desquamation, and the disease terminates in seven or eight days, unless there is a neAV eruption. In many cases it continues for weeks or months by the appearance of successive crops of papulae. Litchen urticatus usually appears suddenly in the form of large and numerous papulae, attended with a burning, distressing pru- ritus. It appears most frequently on the face, neck, and ex- tremities, and is irregular and transitory, subsiding and reap- pearing with great rapidity. "The papulae are clustered, and they are either AA'hite or surrounded by a faint-red areola ; some- times they are prominent, and considerably inflamed, and at first bear considerable resemblance to flea-bites." AVhen scratched or otherwise irritated, they frequently bleed, and dark scabs form on their surface. The eruption may disappear with one 474 DISEASES OF CHILDREN. crop of papulae, but it is occasionally very obstinate, lasting for months, by their successive reproduction. Lichen agrius may appear spontaneously, or it may succeed lichen simplex. AVhen it appears spontaneously, the papulae are very small, red, accumulated, inflamed anel developed on an erythematous surface of limited extent, which is generally attended with heat and painful tension. Instead of subsiding on the fourth or fifth day, they continue increasing; slight ulcera- tions form on their apices, Avhence issues a sero-purulent fluiel, which concretes and forms yellowish, prominent crusts, soft anel slightly adherent. These incrustations fall off, and are then re- placed by thin scaly scabs. Sometimes the redness diminishes, the inflammation disappears, slight desquamation ensues, and the disease terminates about the tAvelfth or fifteenth day. But frequently the discharge continues, and neAV crusts are formed, by Avhich the disease is prolonged considerably. The itching which accompanies it is often so intense that the patient seeks the hardest substances to rub himself with, and thus invariably aggravates the pruritus. It may continue in this manner for several Aveeks, or it may pass into the chronic state, Avhen the scaly incrustations disappear, and are succeeded by slight exfoli- ation, anel the skin is often considerably hypertrophied. This form may last for months.—(Cazenave.) A peculiar form of disease has prevailed extensively in the AVestern country, for the last twenty years, known as Illinois itch, soldiers* itch, etc., presenting many of the characteristics above named. Its symptoms seem so variable, that it is difficult to classify it, as it sometimes resembles eczema, and at others im- petigo, and in others, again, it presents to some extent the characteristics of all three. It appears most generally upon the wrists and hands first, and then extends to various parts of the body, and is remarkably persistent and annoying. Diagnosis.—The diagnosis of litchen is very difficult, as it may be mistaken for eczema, porrigo, scabies, or impetigo, but it may usually be determined by the presence of some of the characteristic papulae. Treatment.—Lichen agrius is more difficult to manage, and no remedy seems to ansAver in all cases. In some, I have had very good success Avith glycerine and tincture of muriate of iron prurigo. 475 in the proportion three parts of the first to one of the last, given internally in teaspoonful doses four times a day. A lotion of muriate of ammonia has been frequently employed, composed of—Py Ilydrochlorate of Ammonia 5j., vinegar 5iv., water Oj., and applied freely to the affected parts. In some cases the in- ternal administration of the compound tincture of Corydalis, with iodide of potassium, and a wash of a decoction of equal parts of Cornus, Alnus, and Rumex, has answered a good purpose. In other cases a lotion of—R/ Glycerine gij.; Oxide of Zinc, oss., Morphia grs. v., Rose-Avater 5*iv., has answered an excellent purpose, as has the ointment of elder and the mild zinc oinf- ment. In other cases, good results Avill be obtained by the internal use of sulphur, and its local employment as a bath, Avash, or ointment. PRURIGO. Several varieties of this disease are described, but many of them are named, not from any prominent difference of symptoms but more on account of their location. The disease is character- ized by the appearance of papulae, usually larger than those of lichen, and Avithout discoloration of the skin, which are attended by very severe pruritus, and sometimes burning. Three varie- ties may be named, P. mitis, P. formicans, P. senilis. Prurigo mitis is the mildest form' of the disease, and is usually acute. The papulae are slightly prominent, but very small, and accompanied with intense itching. In prurigo formicans the papulae are much larger, and flattened, and distinct, and accom- panied with an intolerable pruritus, which increases at night, and by the Avarmth of the bed. If not irritated by scratching, they frequently disappear in the course of one or two Aveeks, but frequently the skin is torn in the efforts for relief, and the part bleeds, and a dark thin scab is formed on its surface. It may continue for a considerable time by continued development of the eruption. In old people, or in Aveakly children, the papulae are frequently large and prominent, and the skin becomes thickened and inflamed ; vesicles, pustules, and boils form, and beino- opened bv scratching give rise to unpleasant excoriations and superficial ulcers, anel a most intense burning and itching. It mav thus last for months, or even years. Prurigo may attack any part of the body, but is most severe Avhen it attacks the rrcnitial organs, or is situated around the anus. 476 DISEASES OF CHILDREN. Diagnosis.—Prurigo may be distinguished from lichen by its larger papulae, and the dark incrustations Avhich are sometimes farmed on them; from scabies by the accumulated vesicles of the latter, and their rose-colored base. It may be associated with lichen, scabies, eczema, impetigo and ecthyma, and in such cases the diagnosis will of course be difficult. Treatment.—In the milder forms of the disease, the re- moval of any internal irritation, and soothing local applications, are all that is required. Frequently it is desirable to keep the boAvels open with a saline purgative, and give an alkaline diure- tic, Avith some gentle diaphoretic. As a local application, the glycerine lotion Avill ansAver a very good purpose; or Ave may use it Avith chloroform, adding ten or fifteen drops of it to each ounce of the lotion. A solution of borax answers a very good purpose, as—Py Borax 5'j-, Morphia gr. v., Rose-Avater §vj. A decoction of Hydrastis or Cornus, with borax and morphia, is frequently beneficial. N^EVUS MATERNI. It is generally supposed, and I think Avith truth, that certain impressions made upon the mother's mind during pregnancy will affect the groAvth and structure of the child, and in some manner deform it. It is true that we can not account in a rational man- ner for any such occurrence, but the instances are so numerous that Ave can not dispute the connection betAveen the impression and the mark. Very frequently we find women making anxious inquiry with regard to the matter, as they are strongly impressed that they have received some shock or sudden impression which Avill mark or deform the child. As it is so rarely that nsevi result from these impressions, Ave are safe in giving such assurance to the prospective mother as will quiet her fears. Numerous instances are related to prove the relation betAveen the impression on the mother's mind and the deformity of the chilel. The severest case of the kind that ever came under my observation Avas a child born Avith a hand so completely deformed as to be useless, and which Avas attributed to the mother's Avit- nessing the dressing of a hand that had been crushed in a thresh- ing machine. In another case the child had a vascular naevus N^EVUS MATERNI. 477 on the cheek, immediately below the eye. The mother attributed the mark to her husband's throAving a cherry at her, which, strik- ing upon the same part of the cheek, burst, and not only star- tled her at the time, but firmly impressed her mind that the child would be marked. The deformities and distortions, that are rarely met with, may frequently be remedied by the surgeon, as in talipes, hair-lip, cleft-palate, etc., but Ave Avill not attempt to describe them here. The most common form of mother's mark is a discoloration of the skin, from an increase in the size of the blood-vessels. It may be located upon any part, and usually increases in size as the child groA\*s. In some cases it is so large at birth that it is useless to interfere, as Avhere it hwolves one-fourth, or sometimes one-half of the face. In other cases it is but the size of a five or tei\ cent piece, and frequently not larger than a grain of Avheat. There is much difference in the rapidity of groAvth. In some it is very sIoav, so that the spot will not have doubled in size to adult years; in others it grows rapidly, and Avill have doubled its size the first month. In the first operative interference is not so necessary, and maybe postponed; in the second the naevus should be remoA'ed as early as possible. The vascularity varies in different cases. In some it is a true anastomotic aneurism, occasionally distinctly pulsating. In these much care should be used to prevent hemorrhage in any opera- tion that may be undertaken. In others the disease is Avholly confined to the capillaries, and the operation outside of the spot Avill not cause greater hemor- rhage than for any other purpose. The bright vivid coloration is met Avith in those cases Avhere the arterial capillaries are involved; the purplish discoloration Avhere the veins are dilated. AAre rarely meet Avith a case upon the skin where the groAvth is such as to form a red tumor, projecting from the skin. Bnt when it is at the junction of the skin and mucous membrane, as on the lip, or Avhdly of the mucous membrane, as sometimes of the tongue or mouth, and occasionally about the reproductive organs, Ave frequently find it assuming the form of an erectile tumor. Occasionally the structure gives Avay in such cases, and there is profuse hemorrhage. 478 DISEASES OF CHILDREN. Treatment.—A great many plans of treatment have been recommended for naevus. The most commonly adopted are by excision, strangulation by ligature, and removal with escharotics. AVhere the groAvth is not markedly vascular, the smaller capil- laries being alone involved, the best plan is to excise the growth. AVhere the tissues are loose, or Avhen the groAvth is oblong or oval in form, the edges may be drawn together with silver sutures, and union obtained without any scar. If the surgeon fears hemorrhage, he inserts his ligatures before operating. The needle is carried through the sound skin, anel beneath the naevus, drawing the Avire through and clipping it at proper length. Enough are inserted in this Avay to insure an arrest of bleeding. Strangulation by ligature is performed by transfixing the base of the groAvth one or more times, and tying it in separate parts so tightly as to cut off the circulation. Probably nitric acid is the best caustic fin* the remo\Tal of naevi. Sir B. Brodie remarked : "Caustics may be used with advantage in congenital tumors, naevi, etc. Little vascular spots on child- ren's faces are an object of anxiety. If you look at these, you will see one large vessel and several branches supplying them. You may destroy them in the folloAving manner: Take a glass pen [a pine stick pointed ansAvers the same purpose] which Avill hold nitric acid, and apply it to the principal vessel, puncture it, and insert into the puncture a fine point of potassa fusa ; a mo- ment's touch Avill be sufficient to destroy the vessel; if the po- tassa extends further than you intended, apply vinegar. You may thus obliterate the vessel Avithout leaving a scar. There are some congenital naevi abounding in the skin, formed by an intricate mesh of vessels; the skin is elevated and of a mulberry color. Tf these are of a large size, they must, be destroyed by ligature or the knife; if of smaller size you may use caustics not unprofitably. The nitric acid is the best application; this makes a slough, the blood coagulates and the parts become in- durated. This is only applied Avhen naevi are of small size. In subcutaneous naevi, Avhich are not of the same color but purple, caustics may be applied to effect their destruction, Avhether of a large or small size ; the great object is to destroy them with caustics rather than the ligature. These naevi have been cured by application of vaccine matter, which acts by producing a N.EVUS MATERNI. 479 slough. You may cure these subcutaneous naevi upon the same principle; puncture them with a finely-pointed lancet, then having a probe armed Avith nitrate of silver, introduce it into the puncture—the caustic presently causes sloughing, and the vessels are obliterated." Lately the removal of naevi by the use of hypodermic injec- tions into the growth, has been strongly recommended. The solution of per-sulphate of iron has been employed in this Avay, and it is claimeel with great success. One fatal case, however, has been reported, in Avhich the death Avas evidently due to the injection. AVhen the naevus is quite superficial, its removal may be at- tempted by the use of a strong tincture of iodine. A very good formula is—Py Tincture of Iodine (to saturation), Aqua Ammo- nia, eta. Sj.; let it stand in a well-corked bottle for a week, and it is ready for use. Apply this daily with a camel's-hair brush, and the naevus will gradually yield. I 1ST IDE X. Action of remedies....................... 21 Acids................................57, 104, 96 Acid, hydrochloric...................57, 96 sulphurous........................97, 101 nitric............:......................108 Acetate of potash......................... 84 Acetous tincture of Lobelia............ 71 Aconite.............................42, 56, 62 JSther....................................... 36 Agrimonia.................................. 86 Ague........................................144 Air.....................................55, 112 Alkaline salts.............................. 58 Aloes......................................... 84 Alteratives................................. 52 Albuminuria..............................363 Albugo .....................................435 Alstonia...... ........:.................... 107 Ammonium carb.......................... 39 bromide of............................ 31 Amygdalis................................. 73 Antierysipelatous .....................109 Antiperiodics...............................105 Antirheumatics..........................102 Antiseptics..................................10C Antispasmodics............................ 26 Antizymotics............................... 95 Analysis of disease....................... 21 Anus, prolapse of............ Appendages of the eyes... Apis.............................. Apocynum...................... Aphthae..............•.................. Arsenic.................................9^. Ascaris.................................... 34j Asafcetida.................................. 40 Asclepias................................... 9" Asthenic bronchitis.....................270 (48 .94, .79. .338 .427 111 103 ,294 108 B Baths...................................... 5i; 88 alkaline sponge..................52, 89 acid sponge.......................52, 89 cold pack...........................51, 89 hot pack............................51, 90 hot foot................................ 90 hot sponge............................. 90 hot....................................... 91 inunction............................. 91 stimulant.............................. 53 tonic................................... 53 Baptisia..................................57, 98 Belladonna.........................28, 85, 94 Benzoate of lithia........................ 87 Bites and stings..........................240 Bryonia.......................30, 57, 63, 103 Bromide of ammonium................. 31 Bronchial catarrh........................270 Bronchitis, asthenic.....................270 acute..................................274 chronic................................278 Breast pump...............................124 Brain, dropsy of........................395 inflammation of....................385 determination to.....................383 congestion of. .......................384 Camphor.................................... 36 Care after birth..........................119 Catarrh, bronchial........................270 Care of the teeth..........................255 Cancrum oris.............................298 Caruncula lachrymalis..................430 Carbolic acid.............................. 101 Calculi....................................372 Cathartics................................... 72 Cerebro-spinal meningitis.............178 1) 482 INDEX. Chloroform................................. 36 Chamomilla............................75, 115 Chronic catarrh...........................246 bronchitis..............................278 hydrocephalus.-.....................395 pharyngitis...........................2C5 nephritis................... ...........36 Chloral hydrate........................... 38 Chlorate of potash..................98, 116 Chloride of lead...........................102 lime....................................101 Cholera infantum........................322 Chlorinated soda........................ 101 Chorea............................*..........415 Chionanthus............................... 76 Chelidonium.............................. 77 Chafing.......................................123 Circulation, derangements of......... 41 remedies influencing............... 41 Cinchonidia................................107 Classification of remedies.............. 25 of disease...............................140 of fevers..............................142 Clothing the child........................120 Compound powder of rhubarb....... 74 Cod-liver oil.............................. 60 Constituents of milk.....................126 Congestive fever...........................123 Continued fever ..........................127 Coryza......................................245 Colic......................................317 Constipation................................336 Congestion of the liver..................346 of the brain..........................384 Convulsions................................410 Conjunctivitis............................432 Cornea, opacity of........................435 Cold pack.................................. 51 Colocynth................................. 75 Consumption ............................. 285 Cow-pox......................„.............201 Cough........................................243 Croup, mucous.............................257 pseudo-membranous...............261 spasmodic..............................266 Cuprum.....................................117 Curvature of 6pino.......................400 ID Digestive apparatus..................... 20 diseases of............................289 remedies for........................... 69 Dentition............................... ..292 derangements of.....................289 Determination to the brain ...........383 Deafness...................................444 Direct medication........................ 21 Diaphoretics............................... 87 Diuretics.................................. 82 Digitalis..................................... 46 Diphtheria..................................183 Difficulties in nursing the child......124 Dioscorea.................................... 78 Discovery of vaccination...............202 Diarrhoea..................................319 Diabetes..................................365 Diseases of the liver.....................346 nervous system......................382 eyes.....................................424 appendages of the eyes............427 ears......................................436 skin.......................... ..........448 Dysentery...................................333 Dyscrasias..................................232 EJ Ear, foreign bodies in...................438 inflammation of.....................439 Earache......................................438 Ear, examination of......................437 Eczema.......................................458 Ecthyma---................................469 Emetics........................................ 70 Epilepsy.....................................405 Enuresis.....................................370 Enteritis....................................320 Eryngium................................... 85 Ergot......................................... 35 Erythema...................................450 Erysipelas.................................455 Eruptive fevers...........................190 Eupatorium....................45, 64, 85, 93 Euphorbia...............................66, 75 Excretory apparatus.......................... Exercise................................55, 112 Exanthemata..............................449 F Febrile diseases...........................140 Fever, pathology of.....................141 classification of.......................142 intermittent...........................144 masked.................................149 remittent.............................149 INDEX. Fever, slow infantile.....................156 congestive...........................160 continued..............................164 fcyPhoid.................................167 spotted.............................. 172 eruptive...............................190 Febricula...................................142 Ferro-cyanide of potassium........... 40 Fistula lachrymalis.............. ......429 Form of remedies......................... 22 Food.......................................... 54 rules for giving..................... 114 Liebig's..............................125 for the child.......................124 Foreign bodies in the ear...............438 Furuncle....................................427 Gastrodynia............................... 307 Gastric irritation......................... 308 Gastritis..................................310 Gastric intermittent......................146 Gangrenous stomatitis...................298 Gelseminum........................27, 44, 85 Grindelia.................................... 68 Government, moral......................132 Gums, lancing..............................290 H Hamamelis.................... .......48, 175 Hernia.......................................356 Herpes.......................................461 Hives.........................................453 Hot pack.................................... 51 Hot foot-bath.............................. 90 Hot bath................................... 91 How to wean the child..................128 Hydrastis.................................... 78 Hydrochloric acid....................... 96 Hypophosphites............................ 69 Hydrangea................................ 86 Hydrocele................................. 378 Hydrocephalus, acute....................391 I Icterus neonatorum.................... 352 Imperforate urethra ........ .........375 Intermittent fever........................144 nervous.................................I45 .................146 ........146 483 Inoculation................................201 Infantile syphilus.......... .............234 dyspepsia..............................312 Intestinal worms.........................340 Infantile leueorrhoea....................379 Inflammation of the lungs.............280 Infantile therapeutics.................... 17 Irritation, avoidance of.................. 18 Ipecacuanha........................63, 71, 74 Iron...................................110, 116 Iris............................................ 80 Iron, sulphate of..........................101 Ischuria......................................367 Itch..........................................463 Illinois..................................474 gastric.......... inflammatory. jked. 1491 Jaundice.................. .................350 Jenner Dr................................. 202 Kidneys inflammation of...............358 Lachrymal apparatus....................428 sac, inflammation....................428 puncta.................................428 Lancing the gums.................. .....290 Lesions of bloodmaking................ Leptandra ............................... 80 Leucoma....................................435 Leucorrhcea infantile....................379 Lichen.......................................473 Light.........................................112 Life line................................... 137 Lime...................................,......118 Liebig's fold..............................125 Liver, diseases of........................ 346 congestion of.........................346 strumous diseases of...............348 Lithotrity..................................375 Lithotomy...................................375 Local applications to loins ...........368 Lobelia............:........32, 46, 63, 71, 74 Lumbricoid worms......................342 Lycopus --- ......................... 46, 65 Lymph vaccine.................. ........254 M Macrotys...................................103 Manganese sulph....................... 80 Malignant measles...... .................209 scarlet fever..........................214 484 INDEX. Malignant sore throat...................302 Malt.......................................... 80 Medication direct........................ 21 Medicines, classification of............ 25 Mental impressions.....................133 Mentha viridis........................... 83 Medicines which influence the ner- vous system........................... 18 Medicines afterbirth........ ..........123 Medicine, dose of..........:.............. 24 Measles.....................................204 sequela?................................210 Meningitis.................................397 Milk..........................................126 Milaria.......................................458 Milkscall...................................458 Moral government....................... 132 Muco-enteritis ..........................320 Mumps............ ..........................223 N Narcotics................................. 38 Naevus materni............................476 Nepeta cataria............................. 93 Nervous system...........................382 Nephritis, acute..........................3."8 Nettle-rash................................45.T chronic............ ...................361 Nervous system, disease of........... 382 Nebula.......................................435 Nitric acid................................. 62 Nipple shields............................124 Nitre, spirits of.......................... 47 Night terrors .............................421 Nurse, wet...................................127 Nux vomica......................33, 61, 76 Nursing, difficulties in..................126 bottles.................................126 Nursery lamp.............................12b O Objections to weaning................. 129 Obstruction of the puncta.......•.......428 Oedema glottidis..........................268 (Enothera................................. 40 Oil, cod-liver.............................. 60 One thing at a time..................... 22 Onanism ..................................380 Opium............... ....................... 38 Ophthalmia neonatorum...............425 Ophthalmia tarsi...............-.........430 Opacity of the cornea....................435 Otitis.......................................439 Otorrhea................................442 Oxide of zinc............................... 81 F» Paraphymosis.............................377 Paralysis...................................422 Papulae..................................473 Pathology................................134 Parotitis...................................223 Permanganate of potash...............102 Percussion..................................244 Peritonitis..................................354 Pemphigus..................................466 Pepsin........................................ 81 Pertussis ..... .......................221 Phosphate of soda........................ 72 Phosphorus...................39, 59, 67, 116 Phytolocca........................64. 99, 104 Phisiological marriage.................135 Physical diagnosis............»..........242 Phthisis....................................285 Phymosis................................. 377 Phrenitis...................................385 Pharyngitis.................................250 Pleasant remedies........................ 24 Pneumonia.................................280 Podophyllin .....................,......48, 77 Potash, acetate of........................ 84 permanganate of....................102 chlorate of........................... 98 Porrigo.......................................471 Poisonous bites............................240 Preservation of lymph..................207 Prurigo.......................................475 Prolapsus ani.............................338 Pseudo-membranous croup...........261 Ptosis........................................427 Pulsatilla.................................... 32 Pulse...... ..................................139 Q Quinia.......................34, 60, 106, 115 Quin.-y......................................253 R. Remedies, form of........................ 22 pleasant................................ 23 Restoratives..................».............111 Rest....................................... is Respiration.....................*......137, 140 INDEX. 485 Respiratory apparatus, remedies for 62 Re^t necessary........................ 18 Reasons for weaning.....................128 Regular habits.............................131 Remittent fever...........................149 with diseases of the brain........151 with diseases of the lungs........152 slow..................................156 Respiratory apparatus, diseases of...242 Retention of the urine................. 367 Rumex....................................... 68 Rhubarb................................... 73 Rhus Tox..............29, 45, 57, 94, 111 Rhus Aroma............................... 86 Rheum ..................................... 73 Roseola.....................................451 infantilis...............................451 aestiva.............................. 451 annulata.............................452 Rubeola... ..............................207 maligna........................•......209 sequelae of............................210 Rupia.......................................467 simplex..............................467 prominens..........................467 escharotica............................468 Santonine............................. 81, 84 Salicylic acid.........................61, ld3 Salicin..................................... 62 Sanginaria................................ 65 nitrate of.............................. 66 Scillae......................................... 67 Scarlatina..................................212 simplex................................213 anginosa ...........................213 maligna..............................214 sequelae................................216 scald head...........................471 Scrofula...............,..................225 Scabies....................... ...........463 Sedatives................................... 83 action of..... ..................... 83 Senega....................................... 91 Second dentition ........ ..............294 ........................ 93 Serpentaria........................ • Silica........................................117 Skin, remedies lor........................ diseases of ..................... Sleeping............................ 448 130 Slow infantile remittent............156 Small-pox..................................192 Soda..........................................us Sore throat..................................300 malignant.............................302 chronic................................305 Spotted fever.............................172 Spurious vaccination....................205 Sputa.......................................244 Spasmodic croup..........................266 Spinal meningitis........................397 St. Vitus' Dance........................415 Spine, curvature of......................4C0 Sticta...................................67, 104 Stimulants...............................488 Stillingia.................................... 65 Stings.......................................240 Stomatitis simplex.......................293 ulcerata...............................297 gangrenous...........................298 Strumous liver...........................348 Sulphur...............................94, 116 Sulphite of soda.....................98, 111 Sweet spirits of nitre................... 47 Syphilis from vaccination..............206 Syphilis, infantile........................234 X Tabes mesenterica....................... 330 Taenia........................................342 Test for milk.............................125 Tetter.......................................459 Temperature................................137 Teeth, care of..............................291 Tinctures preferred...................... 23 Tincture of iron...........................110 Thymol....................................100 Tonics ...................................115 Tonsillitis....................................253 Trismus nascentium.....................420 Trichiasis....................................428 Typhoid fever...... .....................167 U Ulceration of the umbilicus......... 122 Ulcerated sore mouth....................297 Umbilical hernia.......................257 Urethritis ................................377 Urine, suppression of..................367 retention of..........................368 Urinary calculi..........................377 Urethra, imperforate..................375 486 INDEX. Urinary apparatus, diseases of.......358 remedies for.,........................ 82 Urticaria................................. 453 Urine, incontinence of..................370 Uvedalia......... .........................109 Variola.....................................-192 Varioloid....................................200 Vaccine disease.........................201 Vaccination................................203 Vaccine, discovery of...................202 vesicle.................................204 Vaccination, spurious............ 204, 205 syphilis from........................206 Vesiculae.....................................458 Veratrum....................43, 56, 63, 111 Viability..................................137 W Warm water.............................. 92 Warm drinks ............................ 92 Washing the child.......................119 how often.............................121 Wet-sheet pack.......................... 51 Weaning the child ....................128 reasons for.........................128 objections to..........................129 how to.............................129 Wet-nurse...... ........ ....................127 Whooping cough..........................221 Worms, intestinal..................... 340 long round...........................342 thread.................................342 tape......................................342 Z Zinc oxide............... ............... .. 81 Zymosis.......................................95 COMPLETE DESCRIPTION and PRICE LIST OF MEDICAL BOOKS PUBLISHED AND FOR SALE BY JOHN M. SCUDDER, 228 COURT STREET, CINCINNATI, O. 1888. Any book in this list sent post-paid on receipt of price. —-t^m-— TT S a school of medicine we profess to have a distinctive practice, unlike Q/i. either our old school or homeopathic neighbors. We claim to use differ- ent remedies, or in different form and dose, and for different effects. We boldly claim a more successful practice than either of our competitors, and this claim can only be based upon different principles, a different therapeutics, and a different materia medica. We must, therefore, have distinctive books which clearly state our methods of practice. Old-school works will not serve this purpose, neither will homeo- pathic. With the pretensions we make, if we can not show that we have such works, and depend upon them, we are frauds of the first magnitude. In the early days of Eclecticism, the need of text-books was clearly seen, and great sacrifices were made to furnish them. The writers toiled without pay, and to publish the earlier works they practiced the most rigid economy for years to command the money. By these means we had Beach's works, Jones and Morrow's Practice, King's Dispensatory, and some others. The making of books was not an easy nor a profitable job. Now we have a full list of text-books, or books of reference, and by frequent revision they are kept fully up to our practice of to-day. They have been very successful, more so than any American books in the market, and this is the best evidem-e of their value. They are bought by all schools of medicine, and when bought they are brought into active use. ECLECTIC PRACTICE OF MEDICINE. By JOHN M. SCUDDER, M. D. The best recommendation of this work comes in the statement, "twelfth edi- tion." It is the authority of our school of medicine, and thousands of sick are daily treated according to it. Thus far it has proven sufficient, and it has given a success that others have failed to obtain. Twelfth edition, revised : S mo., Sle5 pp.. Sheep ; 87.(X) post-paid ; fij.00 postpaid to Journal Subscriber*. THE Principles of Medicine. By JOHX M. SCl'DDER, M. D. This is a study of the elements of disease and the principles of cure. It is the basis of our practice, and, as we think, of the practice of the future. It gives a rational basis for medical practice. Fifth edition ; 8 mo., :ivj pp., Sheep . post-paid, $-1.00. T I—T F^ EgLEgTIg PRAGTIGE IN DISEASES OP gHILDREN. By JOHN M. SCUDDER, M. D. If there is one thing more than another that we take pride in, it is our suc- cess in the treatment of children. The teaching of pleasant remedies, in small doses, for direct effect, has relieved thousands of children from the horrors of "regular" medicine. Fifth edition ; 8 mo., 186 pp., Sheep ; post-paid, 85.0O. A PRACTICAL Treatise on the Diseases of Women, ILLUSTRATED BY Colored Plates and Numerous Wood Engravings. By JOHX M. SCUDDER, M. D. With a Paper on the Diseases of the Breast, by Robert S. Newton, M D. Late Professor of Surgery in the Eclectic Medical Institvte of Cincinnati.' This work has stood the test of twenty years, and as revised it gives our treatment of to-day. Fourteenth edition, revised : S mo., 531 pp., Sheep; post-paid. 84.00. Specific Medication and Specific Medicines by jo*;::> m. scudder, m. d. Eleventh edition, fourth revision ; 12 mo., i:.;-_> pp., Cloth ; Price, $2.50. SPECIF~IC~DIAGNOSIS. By JOHX M. SCUDDER, M. D. Seventh edition ; IJ mo., 388 pp., Cloth ; Price, $2.50. These companion volumes have had a larger sale than anv other medical works in this country. They appeal to the feeling everv thinking physician cherishes that there must be something certain in medicine, if it can "be dis- covered. They have had a very marked influence upon medical practice not only of our own school, but also on regular medicine and homeopathy. THE AMERICAN ECLECTIC Materia Medica and Therapeutics. By JOHX M. SCUDDER, M. D. Tenth edition ; 8 mo., 748 pp., Sheep; post-paid $•"»-<>>) THE ECLECTIC Practice of Medicine for Families, By JOHX M. SCUDDER, M. D. Twenty-first edition; Cloth, $300; Sheep, $4.00; half Morocco, S'.MO This work contains all of medicine that a family should know. It is anato- my, physiology, hygiene, practice, materia medica, surgery, and obstetrics. It is concise, plain and correct, and will not lead to household drugging. Liberal offers to agents. Write for terms. ON THE Reproductive Organsmp™LVenereal By JOHX M. SCUDDER, M. D. With Colored Illustrations of Syphilis. Second edition ; 8 mo., 393 pp., Sheep : post-paid, $5.00. our Prof. JOHN KING, who has been a teacher for nearly half a CENTURY, IS TOO WELL KNOWN TO REQUIRE MORE THAN A CATALOGUE OF HIS BOOKS. THEY ARE AS FOLLOWS : THE AMERICAN DISPENSATORY. With Supplement by J. U. Lloyd. Tenth edition ; Sheep : Price, $10.00. DMN0S1S"anelTREATMENT of GMROM DISEASES 1700 pages; Sheep; Price, $10.00. The American Eclectic Obstetrics. Fourth edition ; Sheep : Price, $0.50. WOMAN/HER^ISEASES AND THEIR TREATMENT Fourth edition ; Sheep ; Price, $3.50. Urological Dictionary- Sheep; Price, $3.00. prof. HOWE is recognized as one of the ablest teachers in this COUNTRY, AND AN OPERATING SURGEON WITH BUT FEW PEER8 IN THE WE8T. THE ART AND SCIENCE OF SURGERY. Revised edition ; 8 mo.. K86 pp., Sheep ; Price, $7.00. Diagnosis and Treatment of Dislocations and Fractures Third edition ; 426 pp., Sheep ; Price, $400. Manual of Eye Surgery. S mo., '204 pp., e^-loth; Price, $2.50. THE CHEMISTRY OF MEDICINES. PRACTICAL, A text and reference book for the use of students, physicians, and pharma- cists. Embodying the principles of chemical philosophy, and their application to those chemicals that are used in medicine and in pharmacy, including all those that are officinal in the Pharmacopoeia of the United States. With fifty original cuts. By J. U. Lloyd, Professor of Chemistry anel Pharmacy in the Eclectic Medical Institute, Cincinnati, O.; corresponding member of the College of Pharmacy of the City of New York; associate author of the Supplement to the American Dispensate>ry ; author of the Pharmacy and Chemistry of the Student's Pocket Medical Lexicon. One volume; large 12 mo., 451 pp.; Cloth, $2.75: Leather, $3.25. Other Books not Previously Mentioned, ON INHALATIONS. John M. Scudder. Cloth........ $100 PATHOLOGICAL ANATOMY. J. A. Jeancon. 25 parts, $1.00 per part, or bound complete. Cloth............. 30 00 GRAY'S ANATOMY. Sheep, 7.00; with Colored Plates, 8 25 HOLDEN'S ANATOMY. Oil-cloth.................... 4 50 DUNGLISON'S DICTIONARY. Sheep................ 7 50 THOMAS' MEDICAL DICTIONARY. Cloth, $5.00; Slip, 6 00 HUXLEY AND YOUMAN'S PHYSIOLOGY. Cloth... 1 60 CLEVELAND'S LEXICON........Cloth, $1.00; Leather, 1 25 STEELE'S PHYSICS.................................. 1 17 TENNY'S NATURAL HISTORY...................... 1 38 HUXLEY & YOUMAN'S BIOLOGY.................. 1 50 BASTIN S BOTANY................................... 2 50 FOSTER'S PHYSIOLOGY..........Cloth, $3.25 : Sheep. 3 75 PITZER ON ELECTRICITY........................... 1 (X) MERRILL'S MATERIA MEDICA..................... 4 00 CLARES DISEASES OF WOMEN. Sheep............ 4 00 Any other medical book, not enumerated in this list, sent post paid on receipt of publisher's price. J. M. SCUDDER. Cincinnati, O. APR 4 1960 fa